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THE  LECTURES  OF  BOTER 

UPON 

DISEASES  OF  THE  BONES, 

ARRANGED   INTO    A    SYSTEMATIC   TREATISE, 

BY  A.  RICHERAND, 

PROFESSOR    OK    ANATOMY    AND    PHILOSOPHY,    AND    PRINCIPAL    SURGEON 
TO    THE    NORTHERN    HOSPITAL    AT    PARIS. 

ILLUSTRATED  WITH  PLATES. 

^■»e>«^ 

TRANSLATED     FROM    THE     FRENCH 

By  M,  FARRELL,  M.  D. 
two  volumes  in  one. 

m^^^m. 

THE  FIRST  JMERICJN  EDITION, 

WITH 

NOTES  AND  ADDITIONAL  PLATES, 
By  JOSEPH  HARTSHORNE,  M.  D. 


-~^  PRINTED   AND   SOLD   BY  JAMES   HUMPHREYS, 

Ctrner  of  Second  and  ITa/nut-jtreets, 

1805. 


D'tstriSl  of  Pennsyl'vanla,  to  nvii  : 

BE  IT  REMEMBERED  that  on  the  fifth  day  of  August, 
in  the  thirtieth  year  of  the  Independence  of  the  United  States  of  Ante' 
rica.  A.D.  1805,  Joseph  Hartshorne,  of  the  said  distri£l,  hath  de- 
posited in  this  ojffice  the  Title  of  a  Book,  the  right  'whereof  he  claims  as 
Proprietor,  in  the  lucrds  follonuing,  to  «wit : 

"  The  Lectures  of  B oyer  upon  Diseases  of  the  Bones,  arranged 
"  into  a  Systematic  Treatise,  by  A.  Richerand,  Professor  of  Ana- 
"  tomy  and  Philosophy,  and  Principal  Surgeon  to  the  Northern  Hos- 
*'  pital  at  Paris — Illustrated  ixjith  Plates^Translated  from  the 
*'  French  hy  M.  Parrel,  M.D. — Tt^-o  Volumes  in  one.-— The  first 
*'  American  Edition,  ivith  Notes  and  Additional  Plates,  by  Joseph 
"  Hartshorne,  M.  D^ 

In  conformity  to  the  aSl  of  the  Congress  of  the  United  States,  intituled, 
"  an  Ad  for  the  encouragement  of  learning,  by  securing  the  copies  of 
maps,  charts,  and  book;,  to  the  authors  and  proprietors  of  such  copies 
during  the  times  therein  mentioned'^— and  also  to  the  ad  entitled,  "an 
ad  supplementary  to  an  ad,  entitled,  ' '  an  ad  for  the  encouragement  of 
learning,  by  securing  the  copies  of  maps  charts,  and  books,  to  the  authors 
and  proprietors  of  such  copies  during  the  times  therein  mentioned, ^^  and 
extending  the  benefits  thereof  to  the  arts  of  designing,  engraving,  and 
etching  historical  and  other  prints.^' 

D.  CALDWELL, 

Clerk  of  the  Distrid  of  Pennsylvania, 


3  71  iL 


TRANSLATOR'S  PREFACE. 


THE  celebrity  of  the  Authors  of  this  Treatise 
entitles  it  to  a  considerable  share  of  attention. 
Boyer,  a  distinguished  professor  of  surgical  pathology, 
and  an  eminent  practitioner  of  surgery,  who  is  the 
principal  author,  would  have  contented  himself  with 
delivering  the  substance  of  it  in  his  public  Lectures, 
had  not  some  of  his  pupils  attempted  to  publish  from 
their  notes  a  spurious  edition  of  the  work.  These 
copyists  presented  Boyer's  doctrine  in  so  mutilated 
a  form,  that  it  was  found  necessary  to  give  a  genuine 
edition  of  the  Lectures  to  the  public.  Richerand, 
professor  of  anatomy  and  physiology,  and  practitioner 
of  surgery,  in  which  department  he  has  distinguished 
himself  by  his  writings,*  at  the  request  of  his  friend 
Boyer,  and  immediately,  under  his  inspection,  under- 
took this  task:  but  he  has  not  confined  himself  to  the 
duty  of  a  compiler;  he  has  enriched  the  work  by- 
many  of  his  own  observations. 

The  want  of  a  complete  treatise  in  English,  on 
the  Diseases  of  the  Bones,  must  have  been  felt  by- 
students   in   surgery.     The  present  work,  it   is  pre- 

•  See  Professor  Richerand's  Elements  of  Physiology,  tramlated 
from  the  French  by  R.  Kerrison,  8vo.  printed  for  J,  Murray,  32, 
Fleet-street. 


IV  TRANSLATOR  S    PREFACE. 

sumed,  will  not  only  fill  up  this  deficiency,  but  faci- 
litate the  study  of  surgery,  and  expedite  the  progress 
of  those  who  devote  themselves  to  that  branch  of 
medical  knowledge. 

A  scrupulous  attention  has  been  paid  to  preserve 
the  precise  meaning  of  the  authors.  Their  ideas 
have  been  rendered  in  plain  and  intelligible  language  • 
and  it  is  hoped  that  the  work,  as  it  is  now  presented 
to  the  public,  will  answer  the  same  purposes  to  the 
English  reader,  that  the  original  does  to  the  French, 


ERRATA. 

Page  II,  line  lo  from  the  bottom,  for  astragolos  read  astragalus, 
34,  line  17,  for  though  read  through. 
40,  line  2,  for  Fabrice  de  H'dden  read  Fabricius  H'lldanus.* 

44,  line  20,  for  analogously  read  analogous,* 

45,  line  1 1  from  the  bottom,  and  page  82,  line  10  from  the  bottom, 

for  Ledran  read  Le  Dran.* 
109,  line  7,  for  tear  read  hear. 
116,  line  2  from  the  bottom,  (or  greatb  read  great. 
121,  line  22,  dele  the.* 

121,  line  4  from  the  bottom,  for  Hook  read  Gooch.f 
J56,  line  5  from  the  bottom,  for  parietal  rtad  parietal.* 
343,  line  2  from  the  bottom,  for  ad-vantage  read  disadvantage, 
251,  line  3  from  the  bottom,  for  latterly  read  laterally. 
305,  line  4,  for  bare  read  bear. 

*  These  are  errors  of  the  London  copy. 

f  This  also  is  an  error,  (and  probably  a  typographical  error),  of  the  London 
edition.  See  Benjamin  Bell's  System  of  Surgery,  or  Gooch's  Medical  and  Chirur- 
gical  Observations. 


CONTENTS. 


VOLUME  I. 

PACE 

Introduction 9 

CHAPTER  I. 

Or  Fractures  in  general.   . ii 

§  I.  Of  the  different  Species  of  FraSure       .     .      .      .  ib. 

§  2.  Of  the  Causes  of  Fra£lures l8 

§  3.  Of  the  Signs  of  Fraclures ,    .  19 

§  4.  The  Prognosis  of  Fractures        7.\ 

§  5.  Of  the  Treatment  of  Fradures  ....;.  23 

§  6.  Of  the  Formation  of  Callus 36 

CHAP.  II. 
Of  the  Fractures  of   the  Bones  of  the  Nose    46 

CHAP.  III. 
Of   the  Fractures  of  the  Lower  Jaw  .     ,     .     218 

CHAP.  IV. 
Of  the  Fractures  of   the  Vertebra      ...     54 

CHAP.  V. 

Of  the  Fractures  of  the  Sternum    ....     57 

CHAP.  VI. 
Of  Fractures  of  the  Ribs 59 

CHAP.  VIL 

Of  Fractures  of  the  Bones  of   the  Pelvis     .     64 

§   I .  Of  FraSliires  of  the  Sacrum  .......     ib. 

§   2.  Of  FraSiures  of  the  Os  Coccygis 65 

§   3.   OfFrailuresoftheOssainnominata      ....     66 

CHAP.  VIII. 
Of  Fractures  of  the  Scapula 68 

CHAP.  IX. 
Of  Fractures  of   the  Clavicle 72 

CHAP,  X. 
Of  Fractures  of  the  Humerus 78 


VI  CONTENTS. 

CHAP.    Xr.  PAGE 

Of  Fractures  of  the  Fore-arm 83 

§    I.  Of  FraSlurei  of  both  the  Bones 84 

§   2.  Of  Fraaures  of  the  Radius 87 

§   3.  Of  Fraaures  of  the  Cubitus 88 

§  4.  Of  Fradures  of  the  Olecranon 89 

CHAP.  XII. 

Of  Fractures  of  the  Bones  of   the  Hand      .     .  93 

§    I.      Of  FraSures  of  the  Bones  of  the  Carpus      ....  ib. 

§   2.      Of  Fradures  of  the  BoJies  of  the  Metacarpus    .      .      .  ib. 

§   3 .      Of  Frailures  of  the  Phalanges  of  the  Fingers        ,      ,  94 

CHAP.  Xllf. 
Of  Fractures  of  the  Thigh 96 

CHAP.  XIV. 
Of  Fractures  of   the  Neck  of   the  Femur     .     .  102 

CHAP.  XV. 
Of  Fractures  of  the  Patella 129 

CHAP.  XVI. 

Of  Fractures  of  the  Bones  of   the  Leg    .     .     .  143 

§    1 .      Of  Fraaures  of  both  the  Bones ib. 

§   2.      Of  FraSiures  of  the  Tibia 147 

§   3.     Of  FraSiures  of  the  Fibula 148 

CHAP.  XVII. 
Of  Fractures  of  the  Bones  of  the  Foot       .     .  152 

CHAP.  XVIII. 
Of  Wounds,  and  Denudation,  of  Bones      .     .     .   154 
CHAP.  XIX. 

Of  Necrosis 157 

CHAP.  XX. 
Of  Caries 164 

CHAP.  XX  r. 
Of  Exostosis 17^ 

CHAP.  XXII. 
Of  Osteo-sarcoma  . 182 


CONTENTS.  VI! 

VOLUME  II. 


CHAP.    I.  PACE 

Of  Rickets 189 

CHAP.  II. 
Of  the  Fragility  of  Bones 197 

CHAP.  III. 

Of  Sprains 199 

CHAP.  IV. 

Of  Luxations   in   general 204 

§   I.      Of  the  Differences  of  Luxations 205 

§   2.      Of  the  Causes  of  Luxations 207 

§    3.      Of  the  Symptoms  of  Luxation 209 

§  4.      Of  the  Prognosis  in  Luxations 21 1 

§  5.     General  Treatment  of  Luxations 212 

CHAP.  V. 
Of  Luxations  of  the  Lower   Jaw    ......  220 

CHAP.  VL 

Of  Luxations  of   the  Vertebra 225 

§   I.     Of  Luxations  of  the  Head  from  the  first  Vertebra     .   226 
§  2.     Of  Luxations  of  the  first  cervical  Vertebra  from  the 

second ib. 

CHAP.  VII. 
Of  Luxations  of   the  Bones  of   the  Pelvis    .     .   230 

CHAP.  VIII. 

Of  Luxations  of   the   Clavicle 234 

§   I.     Of  Luxations  of  the  Extremity  next  the  Sternum  .      .  ib. 
§  2.     Of  Luxations  of  the  Extremity  next  the  Humerus  .      •237 

CHAP.  IX. 
Of  Luxations  of   the  Os   Humeri 239 

CHAP.  X. 

Of  Luxations  of   the  Fore-arm 251 

§   I.      Of  Luxations  of  the  Fore-arm  from  the  Humerus  .     •     ib. 
§  2,      Of  Luxations  of  the  superior  Extremity  of  the  Radius 

from  the  Ulna 255 

^  3.     Of  Luxations  of  the  inferior  Extremity  of  the  Ulna    .  257 


VIU  CONTENTS. 

CHAP.  XL  PAGE 

Of  Luxations  of  the  Hand 259 

§   1.     Of  Luxations  of  the  Wrist «     .    ib. 

§  2.     Of  Luxations  of  the  Bones  of  the  Carpus  and  Meta- 
carpus   '.     » 261 

§  3.     Of  Luxations  of  ihe  Fingers 262 

CHAP.  XIL 
Of  Luxations  of  the  Femur       .......  264 

CHAP.  XIIL 
Of  Spontaneous  Luxations  of   the  Femur      .    .  271 

CHAP.  XIV. 
Of  Luxations  of  the  Patella    .     t 278 

CHAP.  XV. 
Of  Luxations  of  the  Bones  of   the  Leg     .     «     .  282 

CHAP.  XVL 
Of  Luxations  of  the  Foot 284 

CHAP.  xvn. 

Of  Dropsy  of  the  Articulations 288 

CHAP.  xvin. 

Of  Foreign  Bodies   formed   in   the  Articu- 
lations        293 

CHAP.  XIX. 
Of  Wounds  of  the  Articulations 297 

CHAP.  XX. 
Of  White  Swellings  of  the  Joints 301 

CHAP.  XXL 
Of  Anchylosis .     ;     .  310 

CHAP.  XXIL 

Of  the  Deviations  of  Bones,  and  the  Means 
used  for  Preventing  and  Correcting  the 
Deformity  arising   from  them 314 

ANALYTICAL  INDEX ; 321 

NOTES .    .    .     •  357 


A  TREATISE, 


INTRODUCTION. 


BONES  are  subjeft  to  the  same  diseases  as  the  soft  parts.  This 
assertion  may  at  first  appear  to  be  made  at  random,  but  its 
truth  will  be  proved  by  the  explanation  into  which  we  are  about  to 
enter.  Hardness,  which  is  their  distinctive  quality,  does  not  belong 
to  them  in  every  stage  of  their  existence;  their  soft  and  gelatinous 
state  in  the  embryo  is  changed  in  a  more  advanced  stage  of  life  to 
that  of  cartilage,  which  finally  hardens  by  the  deposition  of  a 
neutralized  combination  of  lime  and  phosphoric  acid,  in  its  pa- 
renchymatous structure.  To  this  saline  inorganized  substance  is  to 
be  ascribed  whatever  difference  is  found  between  the  bones  and 
soft  parts.  When  deprived  of  this  substance,  whether  artificially, 
by  immersion  in  an  acid,  or  by  the  operation  of  the  disease  call- 
ed rachitis,  they  become  soft  and  flexible,  and  are  reducible,  by 
long  maceration,  to  a  cellular  strudlure,  in  which  vessels  of  every 
species  are  seen  to  ramify. 

The  existence,  however,  of  the  phosphate,  and  of  a  small 
quantity  of  carbonate  of  lime  in  bones,  has  a  great  influence  on 
their  diseases;  the  circulation  is  in  some  degree  obstru<5led  by  the 
presence  of  this  inorganized  matter,  and  all  the  vital  properties 
are  thereby  rendered  more  obscure.  Thus  all  the  diseases  of  the 
bones,  which  depend  on  a  greater  or  less  excitement  of  these 
properties,  are  slow  in  their  progress,  and  of  the  chronic  kind, 
although  similar  affections  of  the  soft  parts  would  produce  acute 
diseases.  A  solution  of  continuity,  for  instance,  or  a  simple 
-wound  of  the  soft  parts,  heals  and  reunites  in  two  or  three  days, 
if  the  parts  be  brought  into  immediate  contadti  but  a  wound  or 


lO  INTRODUCTION. 

fra£hire  of  a  bone  requires  twenty  days  at  least,  not  unfrequently 

forty  or  fifty,  and  even  several  months  in  some  cases;  and  in  ge- 
neral it  may  be  said,  that  the  cure  will  be  slow  in  proportion  to 
the  person's  age;  because,  as  years  increase,  the  proportion  of 
the  saline  part  of  the  bones  increases  also. 

How  much  greater  is  the  duration  of  exostosis  than  of  phleg- 
mon or  any  other  swelling  of  the  soft  parts?  Is  not  necrosis, 
which  is  the  true  gangrene  of  the  bony  substance,  equally  slow? 
Is  not  the  separation  of  the  living  from  the  mortified  part  slower 
than  in  the  gangrene  of  soft  parts?  This  long  duration  of  these 
diseases,  and  the  tardy  succession  of  their  symptoms,  will  be 
greater  or  less  in  proportion  to  the  greater  or  less  relative  quanti- 
ty of  saline  matter  in  the  bones;  whence  it  follows,  that  their 
progress  will  be  quicker  in  the  infant  than  in  the  adult,  and,  ceteris 
paribus,  that  they  will  be  slower  in  old  age  than  at  any  other  pe- 
riod. 

The  best  and  most  ancient  division  of  the  diseases  of  the  bones 
is  that  which  distributes  them  into  two  orders;  the  first  of  which 
comprehends  whatever  afFefts  each  bone  singly,  in  its  substance 
or  continuity;  the  second  comprehends  their  diseases  in  the 
joints,  and  in  their  points  of  contact  one  with  another.  But  it  is 
to  be  oberved,  that  the  diseases  of  this  second  order  may  afFe<n: 
also  the  substance  of  the  bones,  as,  frequently,  in  cases  of  white 
or  lymphatic  swellings  of  th€  joints,  caries  of  the  extremities  of 
the  bones  accompanies  the  morbid  affedlion  of  the  surrounding 
soft  parts. 

The  first  order  of  the  diseases  of  the  bones  comprehends  their 
fractures,  wounds,  exostosis,  necrosis,  and  caries,  the  ricketty 
softening  of  the  bones,  their  friability,  and  that  morbid  state 
known  by  the  name  of  spina  ventosa,  or  osteosarcoma. 

The  second  order  embraces  sprains,  luxations,  dropsy  of  the 
articulations,  the  diseases  arising  from  preternatural  substances 
generated  in  the  articulations,  white  or  lymphatic  swellings,  and 
anchylosis. 

It  shall  be  shewn  in  the  sequel,  that  the  assistance  of  art  is 
indispensable,  and  efficacious  in  the  greater  number  of  these  dis- 
eases. Whatever  relates  to  fraclures  shall  first  be  considered:  Of 
all  the  diseases  of  the  bones  they  are  the  most  frequent;  to  none 
is  a  stridl  attention  more  necessary;  in  the  treatment  of  none  i& 
the  utility  of  the  surgical  art  more  evident. 


II 


CHAPTER  I. 


OF  FRACTURES  IN  GENERAL. 

FRACTURE  is  defined  a  solution  of  continuity  of  one  or  of 
several  bones,  resulting  from  a  force  of  extension  dispropor- 
tionate to,  and  exceeding  their  natural  extensibility.  We  shall  not, 
in  imitation  of  the  greater  part  of  authors,  add,  "  produced  by 
some  external  cause*,"  for  though  the  most  usual  cause  of  fractures 
be  some  external  force,  yet  muscular  force  is  sometimes  the  sole 
cause.  It  is  this  alone  that  always  occasions  the  frafture  of  the 
patella,  olecranon,  and  cakaneum.  This  definition  might  be  ap- 
plied to  a  solution  of  continuity  produced  by  a  cutting  instrument, 
and  therefore  very  different  from  frafture  properly  so  called;  but 
a  rigorous  precision  of  language  is  not  to  be  expecleci,  particular- 
ly in  medical  subjedts. 


SECTION    I. 

Of  the  different  Species  of  FrhSture. 

Fractures  differ  from  one  another  in  five  respects;  1st,  as  to 
the  bone  affedled;  2d,  as  to  the  part  of  the  bone;  3d,  as  to  the 
direction  of  the  fraclure;  4th,  as  to  the  relative  position  of  the 
fractured  portions;  5thly,  and  finally,  as  to  the  attending  circum- 
stances by  which  the  fra(Sl;ure  may  be  either  simple,  or  variously 
complicated.  We  proceed  to  consider  them  successively  in  these 
respects.  The  fraftured  bone  may  be  broad,  such  as  the  scapula, 
or  bones  of  the  pelvis;  ur  short,  as  the  calcaneum  and  astragolos; 
or  belong  to  the  class  of  long  bones,  as  is  most  frequemly  the 
case.  The  situation  and  use  of  the  broad  bones  do  nor  expose 
them  much  to  be  fraclured,  with  the  exception,  however,  of 
those  of  the  cranium;  in  which  case,  the  fracture  is  less  to  be  at- 
tended to  than  the  affedtion  of  the  brain,  v/hich  it  almost  neces- 
sarily occasions. 

The  fradture  of  short  bones  is  still  less  frequent,  on  account  of 
the  equality  of  the  three  dimensions;  and  if  not  produced  by  an 
external  force  or  weight,  which  crushes,  or  rather  grinds  the  part, 


12      ,      OF  FRACTURES  IN  GENERAL. 

is  almost  always  produced  by  muscular  contraction,  which  is  by 
much  the  most  frequent  cause  of  the  fracture  of  the  patella,  of 
the  olecranon,  and  calcaneum.  The  long  bones,  whether  they 
serve  as  pillars,  as  levers,  or  as  arch-ending  points  of  support 
and  resistance,  are  much  exposed  to  fradlure,  and  are  more  fre- 
quently fra(n:ured  than  any  other  class  of  bones;  therefore,  all 
that  is  to  be  said  of  fraflures  in  general,  is  principally  applicable 
to  theiTi. 

These  bones  may  be  fractured  in  different  points  of  their 
length,  and  that  happens  most  frequently  in  the  point  of  bisec- 
tion; in  which  case,  the  fracture  is  produced,  like  that  of  a  stick 
bent  beyond  its  natural  extensibility,  by  a  force  applied  at  each 
extremity.  These  bones  may,  however,  be  fractured  more  or 
less  near  their  extremities;  sometimes  even  it  happens  in  their  ex- 
treme points,  as  shall  be  explained  in  treating  of  the  fractures  of 
the  neck  of  the  femur  and  humerus.  Sometimes,  too,  the  same 
bone  is  fractured  in  different  points,  whether  it  be  caused  by  a 
weight  falling  on  a  fragment  of  a  single  fra£ture,  or  whether  a 
cause  of  that  nature  alone,  and  exclusively  of  any  pre-existing 
fraClure,  break  the  bone  into  several  distinct  splinters.  This  last 
species  of  fradlure,  which  the  ancients  termed  "  nut-like,"  in 
allusion  to  the  breaking  of  a  nut  by  a  hammer,  is  distinguished 
by  the  descriptive  name  of  comminutive  fradture. 

The  differences  relative  to  the  part  of  the  bone  fractured,  esta- 
blish a  distinction  of  great  importance,  and  not  purely  scholastic, 
as  is  imagined  by  some;  for  these  differences  influence  the  treat- 
ment and  prognosis,  as  shall  be  proved.  Thus,  in  a  fradture  of 
the  middle  part  of  a  bone,  though,  on  account  of  the  bone  being 
less  thick  in  that  part,  and  the  contiguous  surfaces  therefore  less 
extensive,  the  fradlured  portions  are  more  easily  and  more  widely 
separable  one  from  the  other,  yet  this  kind  of  fracture  is  the 
least  dangerous;  because,  in  such  cases,  the  cause  is  seldom  ap- 
pUed  to  the  part  fradtured,  and  for  that  reason  the  surrounding 
soft  parts  are  injured  equally  seldom.  Another  reason  of  this 
difference  is,  that  a  less  force  suffices  to  break  the  bone  in  the 
middle  than  in  any  other  part;  besides,  the  means  usually  em- 
ployed to  keep  the  fradtured  portions  in  just  contadl  are  more  ef- 
fedtual,  because  they  are  longer.  Add  to  all  this,  that  inflamma- 
tion, stiffness,  and  anchylosis  of  the  joint,  are  less  likely  to  hap- 
pen than  when  the  bone  is  fradtured  near  the  articulation. 

With  respedl  to  the  diredtion  of  the  fracture,  there  are  several 
distindtions  to  be  made.  It  is  called  transverse  when  its  diredtion 
is  perpendicular  to  the  axis  of  the  bone;  oblique,  when  it  devi- 
ates from  the  perpendicular.     In  this  respedl  also,  the  comminu- 


OF  FRACTURFiS  IN  GENERAL.  IJ 

tlve  fracture  is  to  be  considered  as  of  a  particular  species.  This 
frafture  of  the  bone  into  several  pieces  of  different  diretftions,  is 
always  attended  with  contusion  of  the  surrounding  soft  parts. 
Another  species  of  frafSture  of  a  longitudinal  direftion  has  been 
admitted  by  Duveniey^  of  which  he  quotes  two  cases,  and  com- 
pares it  to  the  cracks  which  sudden  drying  causes  in  a  board  that 
had  been  impregnated  with  humidity.  J.  L.  Petit  has,  with 
reason,  denied  the  possibility  of  this  species  of  fradlure;  arguing, 
that  the  cause  which  could  fradlure  a  bone  longitudinally  would, 
fradlure  it  more  easily  transversely,  and  must  necessarily  have 
done  so.  The  cases  of  these  pretended  fractures  related  by  Du- 
verney  are  by  no  means  satisfaflory;  for  it  is  very  difficult  to  as- 
certain the  existence  of  such  a  fradlure  through  the  skin,  perios- 
teum, and  intermediate  parts.  Heister  admits  its  possibility  how- 
ever, and  even  asserts,  that  the  panaris  is  for  the  most  part  ow- 
ing to  the  longitudinal  fradture  of  the  finger-bones j  but  this  er- 
roneous opinion  has  been  amply  refuted  by  Louis  at  the  conclu- 
sion of  his  discourse  on  Petit's  Treatise  on  the  Diseases  of  the 
Bones.  We  adopt  the  opinion  of  this  latter  author,  and  rejedl  as 
impossible,  the  longitudinal  frafture,  unless  that  name  be  applied 
to  longitudinal  splinters  of  comminutive  fra61ure,  as  is  most  like- 
ly to  happen  when  the  fracture  is  occasioned  by  a  gun-shot. 

The  most  important  distinction  of  fraftures  is  that  resulting 
from  the  different  situations  of  the  fra<5tured  portions;  the  know- 
ledge of  their  derangements  is  of  the  greatest  importance,  be- 
cause the  principal  obje^  in  the  treatment  of  fraftures  is  to  pre- 
vent or  remedy  these  derangements.  The  separation  of  the  frac- 
tured parts  is  not,  however,  essential  to  the  disease,  for  it  oftea 
happens  that  the  leg  is  fractured  without  any  change  in  the  form 
of  the  limb;  and  this  is  particularly  t]ie  case  when  the  tibia  alone 
is  fractured  at  its  superior  extremity,  because  its  diameter  is  con- 
siderable in  that  part,  and  the  extensive  surfaces  in  contadt  can- 
not separate  without  difficulty:  the  fibula  also  contributes  to  re- 
tain the  fradtured  portions  in  their  natural  situation.  But  when 
both  bones  of  the  fore-arm  or  leg  are  fractured,  it  rarely  happens 
that  the  derangement  of  the  parts  is  not  the  distinctive  sign  and 
proof  of  the  accident.  This  derangement  attends,  almost  with- 
out exception,  the  fra£ture  of  the  thigh  and  arm,  these  members 
being  each  formed  of  a  single  bone,  and  surrounded  by  very  pow- 
erful muscles.  The  causes  of  this  derangement,  and  its  varieties, 
shall  next  be  considered. 

It  may  happen  in  the  direction  of  the  diameter  of  the  bone,  be 
parallel  to,  or  form  an  angle  with  the  axis,  or  merely  affe6t  the 
circumference. 


14  OF  FRACTURES  IN  GENERAL. 

When  a  bone  is  fraftured  transversely,  the  contiguous  surfaces 
may  remain  in  partial  contadt,  or  be  totally  separated.  In  a  frac- 
ture of  the  tibia,  for  instance,  the  inferior  portion  of  the  bone 
may  be  pushed  inward,  and  totally  separated  from  the  superior; 
or  the  external  part  of  the  former  may  be  placed  in  contact  with 
the  internal  of  the  latter.  This  incomplete  derangement  in 
the  direction  of  the  diameter  of  the  bone,  does  not  produce  any 
shortening  of  the  limb;  but  when  this  derangement  is  complete^ 
then  follows  that  parallel  to  the  axis  of  the  bone.  The  derange- 
ment in  the  diredtion  of  the  diameter  happens  when  jhe  fradtu- 
red  bone  is  of  a  considerable  size,  as  the  tibia,  for  instance, 
and  the  fradlure  transverse;  and  when  the  proper  means  of  keep- 
ing the  parts  in  their  natural  situation  have  been  too  long  neg- 
lected. But  if  the  fracture  be  oblique,  the  surfaces  not  extensive, 
and  the  accident  negledled,  the  derangement  in  the  diredlion  of 
the  axis  takes  place,  and  the  limb  is  shortened.  In  this  last-men- 
tioned might  be  included  the  fradlure  of  the  patella,  olecranon, 
and  calcancum;  with  this  difference,  however,  that  in  the  latter 
cases  the  fracTtured  ends  recede  one  from  the  other,  and  are  al- 
ways found  separated  by  a  greater  or  less  distance,  instead  of 
passing  one  by  the  other,  as  in  the  former  case. 

The  third  species,  viz.  that  in  which  two  fragments  form  an 
angle  one  with  the  other,  has  not  been  mentioned  by  authors, 
and  takes  place  principally  in  cases  of  comminutive  frafture.  It 
might  happen,  however,  in  a  simple  fradture  of  the  leg,  as  may 
easily  be  conceived  by  supposing  the  foot  placed  on  an  inclined 
plane;  in  which  case  the  angle  formed  would  be  salient  anterior- 
ly, if  the  heel  were  lower  than  the  fore  part  of  the  foot,  posteri.. 
orly  if  the  contrary. 

The  fourth  species,  or  that  affedl:lng  the  circumference,  is  pro- 
duced by  the  rotation  of  the  inferior  fradtured  portion  on  the 
superior,  in  such  a  manner  as  that  the  part  which  was  anterior 
becomes  internal  or  external.  We  have  an  instance  of  this  spe- 
cies of  derangement  in  the  fradture  of  the  neck  of  the  femur; 
when  the  foot  being  ill  supported  by  the  apparatus,  and  obeying 
its  weight,  aided  by  that  of  the  leg  and  by  the  contraction  of  the 
muscles,  turns  outward,  and  carries  the  inferior  fragment  in  the 
same  direction;  in  which  case,  the  anterior  part  of  the  body  of 
the  bone  corresponds  no  longer  to  the  anterior  part  of  the  neck. 

The  bones  being  but  passive  instruments  of  loco-motion,  pos- 
sess not,  in  their  own  organization,  any  cause  of  the  change  of 
situation  which  takes  place,  but  yield  to  exterior  causes,  to  the 
weight  of  the  member,  and  to  muscular  contraction;  whence  it 
appears,  that  the  causes  of  this  change  of  situation  may  be  v-ery. 

,8' 


OF    FRACTURES    IN    GlfNERAL.  I5 

various.  The  cause  of  the  fradlure  may  also  be  the  cause  of  the 
derangement  of  the  fra(^tured  portions;  as  when  the  thigh,  for 
instance,  is  fraftured  by  a  fall  from  some  height:  if  the  weight 
of  the  body,  pressing  on  the  inferior  extremity  which  bears  on 
the  ground,  bends  the  femur  forward,  the  force  will  not  be  en- 
tirely spent  in  producing  the  fracture,  but  will,  in  addition,  pro- 
duce a  greater  or  less  derangement  of  the  fractured  portions. 

The  celebrated  Ambrose  Pare  has  offered,  in  his  own  case,  a 
fracture  and  separation  of  the  bones  produced  by  the  same  cause. 
This  eminent  surgeon  reeeived  a  kick  from  a  horse  on  the  leg, 
with  such  force,  that  the  lower  fracftured  portion  abandoned  en- 
tirely the  upper,  which,  impelled  by  the  weight  of  the  body, 
pierced  the  flesh,  integuments,  stocking,  and  gaitre,  and  drove 
its  pointed  extremity  even  into  the  earth. 

The  -yveight  of  the  limb  suffices  alone  to  produce  the  angular 
derangement,  or  that  affecting  the  circumference,  as  has  been 
already  explained,  when  treating  particularly  on  that  subje£l. 
Another  cause  is,  the  impulse  frequently  communicated  to  the 
limb,  by  the  assistants,  during  the  dressing:  but  of  all  these  cau- 
ses, the  most  powerful  is  the  contraction  of  the  muscles. 

Of  the  muscles  which  surround  a  fraftured  bone,  some  are  at- 
tached to  that  bone  in  a  great  part  of  its  lengih,  and  therefore  in 
many  cases  to  both  portions  of  the  fradtured  bone.  Others  ex- 
tend from  the  bone  which  is  superior  to  that  fradlured,  to  that 
which  articulates  with  the  lower  portion,  or  to  the  lower  frag- 
ment itself;  there  are  still  others  which  terminate  in  the  upper 
fragment,  the  other  extremity  of  which  may  be  more  or  less  dis- 
tant. The  muscles  of  the  thigh  offer  examples  of  these  three 
different  dispositions.  The  triceps  is  attached  to  the  whole  length 
of  the  femur;  the  biceps,  semi  tendinosus,  and  semi-membrano- 
sus,  descend  from  the  pelvis  to  the  leg,  to  which  the  lower  part 
of  the  femur  is  articulated,  and  all  the  movements  of  which  it 
obeys;  the  great  adductor  muscle  has  its  insertion  in  the  lower 
part  of  the  femur  itself:  finally,  the  psoas,  iliacus,  pedlineus,  &c. 
&c.  descend  from  the  loins  and  the  pelvis,  and  have  their  inser- 
tion near  the  superior  extremity  of  the  femur. 

The  muscles  which  are  attached  to  both  portions  of  the  frac- 
tured bone,  contribute  very  little  to  their  change  of  situation; 
but  may,  however,  draw  them  both  to  the  side  on  which  they 
are  inserted,  and  thus  change  the  direftion  of  the  limb.  The 
triceps,  and  more  particularly  its  middle  part,  adls  thus  on  the 
fradlured  femur,  and  renders  the  thigh  convex  anteriorly.  The 
brachialis  anterior  tends  to  produce  the  same  effeft,  when  the  hu- 
merus is  fradtured  below  its  middle  part.     Eut  the  change  from 


l6  OF  FRACTURES  IN  GENERAL. 

the  natural  situation  is  principally  owing  to  the  muscles  which  are 
inserted  into  the  lower  portion  of  the  fradlured  bone,  or  the  limb 
with  which  it  articulates.  Let  us  suppose  the  frafture  of  the  hu- 
merus between  its  superior  extremity  and  the  insertion  of  the 
great  pecloral  muscle;  this  muscle,  aided  by  the  latissimus  dorsi 
and  teres  major,  draws  the  inferior  portion  inward  and  upward, 
and  causes  it  to  ascend  on  the  interior  side  of  the  superior,  which 
rests  motionless  on  account  of  its  shortness,  and  because  the  mus- 
cles, which  are  inserted  into  it,  are  not  a£led  on  by  any  cause 
that  excites  them  to  a6Vion,  In  the  frafture  of  the  neck  of  the 
femur,  the  superior  portion  of  the  fractured  bone  has  no  muscle 
inserted  into  it,  and  remains  motionless  in  the  articulating  cavity. 
Those  muscles  which,  on  the  contrary,  are  attached  to  the  lower 
portion,  draw  it  upward  and  backward,  and  render  its  being  dis- 
placed in  that  direction  inevitable. 

The  lower  portion  being  adled  on  by  the  limb  to  which  it  is  ar- 
ticulated, follows  all  its  motions,  and  is  liable  to  be  displaced  by 
the  acftion  of  the  muscles  which  are  inserted  into  it.  Thus,  in 
fractures  of  the  body  of  the  femur,  the  biceps,  semitendinosus, 
and  other  muscles,  draw  the  leg,  and  with  it  the  inferior  portion, 
upward,  inward,  and  back-ward,  and  cause  it  to  ascend  on  the 
internal,  and  a  little  on  the  posterior  side  of  the  superior  portion, 
the  inferior  extremity  of  which  projects,  in  that  case,  on  the  an- 
terior and  external  side. 

In  the  fra£lures  of  the  leg,  the  gastrocnemii  muscles,  &c.  draw 
the  inferior  portion  upward  and  backward,  with  the  foot-,  for  in 
this,  as  in  every  similar  case,  the  stronger  muscles  displace  the 
lower  portion  of  the  fractured  bone,  and  draw  it  in  their  direc- 
tion: hence  it  is,  that  in  this  case  the  portion  is  drawn  backward  as 
well  as  upward,  because  the  muscles  are  more  numerous  and 
larger  on  the  back  part  of  the  leg  than  on  any  other.  Therefore, 
when  a  fracfture  takes  place  in  any  part  of  a  bone,  it  is  easy  to  de- 
termine, from  a  knowledge  of  the  muscles,  what  species  of  de- 
rangement will  follow,  if  there  be  no  counterafting  cause.  Fi- 
nally, the  muscles  which  have  their  insertion  in  a  superior  frag- 
ment, may  produce  its  separation  from  the  inferior.  When  the 
femur  is  fra<Stured  immediately  below  the  small  trochanter,  the 
iliac  and  psoas  muscles  draw  forward  the  inferior  extremity  of  the 
superior  fragment,  which  raises  the  skin  and  projects  more  or 
less.  It  is  to  be  observed,  however,  that  the  displacing  of  this 
fragment  is  very  rare,  whilst  the  inferior  fragment  is  displaced  in 
almost  every  case. 

Hitherto  we  have  considered  the  derangements  of  fratftures  as 
simple,  but  they  may  be  complicated;  as  for  example,  when  in  a 


OF  FRACTURES  IN  GENERAL.  If 

simple  fra^lure  of  the  femur,  the  lower  fragment  has  ascended 
upward  and  inward,  and  the  foot  being  ill  supported  inclines  ex- 
ternally at  the  same  time.  The  derangement  in  this  case  will  be 
composed  of  the  four  species  already  described. 

There  are  other  differences  still  which  depend  on  the  fracHrures 
being  simple  or  compound.  A  simple  fracture  is  that  in  which 
the  soft  parts  have  received  no  other  injury  than  that  necessarily- 
produced  by  the  frafture;  for  it  is  easy  to  conceive,  that  a  frac- 
ture cannot  take  place  without  lacerating  more  or  less  the  perios- 
teum, the  small  blood-vessels,  and  the  muscular  fibres  contiguous 
to  the  fracture;  some  degree  of  Contusion  and  of  swelling  follows 
necessarily,  and  the  skin  of  the  part  becomes  livid  and  yellow  in 
two  or  three  daj-s.  A  frafture  is  compound  when  it  is  accompa- 
nied by  circumstances  which  require  particular  modes  of  treat- 
ment i  such  are  a  much  greater  degree  of  contusion  than  ordi- 
nary; a  solution  of  continuity  of  the  surrounding  soft  parts,  whe- 
ther that  be  immediately  produced  by  the  fradluring  cause,  or  by 
the  fragments  penetrating  through  the  skin,  after  having  lacerated 
the  intermediate  soft  parts:  this  happens  when  the  fradlure  is  very 
oblique  and  the  fragments  pointed.  This  compound  fracture  may 
be  rendered  still  more  complex,  by  the  rupture  of  a  large  blood- 
vessel, whether  an  artery  or  vein,  and  by  the  effusion  of  blood  in 
the  cellular  texture,  which  would  be  its  necessary  consequence. 

Fra£tures  are  but  rarely  accompanied  with  luxation-,  in  which 
case  the  luxation  must  necessarily  precede  the  fracture;  for  the 
fra<Sture  once  effected,  the  fragments  are  not  susceptible  of  luxa- 
tion: any  motion  which  may  be  communicated  to  them  can  only 
impel  them  into  the  surrounding  soft  parts  producing  more  or  less 
laceration. 

Finally,  fractures  may  be  accompanied  with  other  morbid  af- 
fedlions,  whether  pre-existing  to  the  fracture,  succeding  that  ac- 
cident, or  operating  as  its  predisposing  cause.  Thus  persons  af- 
fe£led  with  a  fradlure,  are  also  often  affected  at  the  same  time 
with  a  vitiated  state  of  the  solids  and  humours;  such  are,  for  in- 
stance, the  scurvy,"  scrofula,  the  venereal  disease,  or  cancer.  Add 
to  all  this,  that  the  irritation  caused  by  a  fracture  may  be  the  occa- 
sion of  an  acute  fever,  which  generally  changes  to  the  reigning 
epidemic. 

We  shall  not  treat  here  of  the  distinftion  of  fra£bjres  into  com- 
plete and  incomplete;  because  these  denominations  appear  to  us 
unfounded,  and  fit  only  to  lead  into  error.  By  complete  fradhires, 
authors  mean  those  in  which  both  bones  of  a  limb  are  at  the  same 
time  fradlurcd;  as  those  of  the  leg  or  fore-arm:  incomplete,  those 
in  which  only  one  of  these  bones  is  fractured,  the  other  not  being 
3 


iS  OF  THE  CAUSES  OF  FRACTURES. 

injured;  but  it  is  evident  that  in  this  case  the  frafture  is  complete; 
for  to  the  term  incomplete,  we  can  only  attach  the  idea  of  a  bone 
partially  fradlured,  an  occurrence  utterly  impossible. 


SECTION   ii. 

'  Of  the  Causes  of  Fra£lures. 

The  causes  of  fraftures  are  as  various  as  the  means  by  virhiclt 
that  efFedt  may  be  produced;  and,  like  the  causes  of  other  dis- 
eases, may  be  divided  into  predisposing,  and  remote.  In  the 
first  class  of  causes  are  ranged  the  situation  and  functions  of  the 
bones,  the  age  of  the  individuals,  and  their  diseases,  if  affefted  by 
any.  Superficial  bones  arc  more  easily  fradVured  than  those  which 
are  covered  by  a  considerable  depth  of  soft  parts.  The  functions 
of  some  bones  render  them  more  liable  to  be  fractured  than  others; 
thus  the  radius,  which  supports  the  hand,  and  serves  in  some 
respect  as  a  handle  to  it,  is  more  liable  to  be  fraftnred  than  the 
cubitus.  The  clavicula,  which  preserves  the  shoulder  and  ster- 
num in  their  proper  position,  and  supports  on  its  arched  extre- 
mity all  the  motions  of  the  superior  extremity,  is  on  that  account 
frequently  fracStured.  The  gradual  accumulation  of  phosphate  of 
lime  in  the  cellular  structure  of  the  bones,  renders  them  brittle 
in  proportion  as  we  advance  in  life.  In  old  age  the  proportion  of 
the  inorganized  to  the  organized  part  is  so  great,  that  the  bones 
are  then  fradlured  by  the  slightest  cause.  In  childhood,  on  the 
contrary,  the  fibrous  and  organized  part  prevails,  and  communi- 
cates its  properties  to  the  bone,  which  is  then  flexible  and  elastic. 
An  advanced  period  of  life  is  theri,  to  be  reckoned  as  one  of  the 
predisposing  causes  of  fradlures.  Certain  acrimonies, a0e<n:  the  os- 
seous system,  by  attacking  its  organized  part,  and  reducing  it  to 
the  same  state  as  in  old  age,  and  render  i-t  even  still  more  brittle. 
Thus,  women  affedced  with  old  and  ulcerated  cancers,  have  been 
known  to  fraftui^e  their  bones,  in  performing  the  natural  and  or- 
dinary motions  of  the  body,  or  merely  in  changing  their  position 
in  bed;  instances  of  which  are  recorded  by  Louis  and  Saviard.  In 
cases  of  this  nature,  all  the  bones  of  the  body  being  equally  af- 
fedled,  several  fractures  happen  at  the  same  time,  and  reduce  the 
sufferer  to  the  lowest  state  of  wretchedness.  The  principal  indi- 
cation in  such  cases  is  not  that  of  the  fracture,  as  it  is  only  a  symp- 
tom of  a  more  dangerous  disease,  the  cure  of  which  ought  prin- 
cipally to  be  attended  to.     A  certain  degree  of  cold  has  been  num- 


OF    THE    CAUSES    OF    FRACTURES.  1 9 

bered  among  the  predisposing  causes  of  frafture;  but  if  this  acci- 
dent be  more  frequent  in  winter  than  in  summer,  it  is  because 
persons  are  then  more  hable  to  accidents  from  faUing. 

Every  efficient  cause  adls  in  overcoming  the  natural  cohesion  of 
the  osseous  particles,  by  separating  these  particles,  and  lengthen- 
ing the  bone  beyond  its  natural  extensibility;  the  force  thus  a<5ling, 
may  have  been  applied  on  the  part  fradlured  immediately,  or  on 
some  distant  part.  When  the  cause  of  the  fracture  is  applied  to 
both  ends  of  a  bone,  the  bone  is  curved  by  the  approximation  of 
its  extremities;  thus  it  is,  that,  by  falling  on  the  shoulder,  the 
clavicle,  forcibly  pressed  against  the  sternum,  is  curved  and  frac- 
tured, as  if  by  wh^t  the  French  term  contrecoup.  In  falling  on  the 
knees,  the  femur,  pressed  between  the  weight  of  the  body  and 
the  ground,  bends  about  its  middle  part,  and  the  fra^ure  takes 
place  there.  In  these  and  similar  cases,  the  natural  curvature  of 
the  bones  contributes,  with  the  force  applied,  to  determine  the 
frafture  in  a  certain  part;  and  in  such  cases  the  contusion  is  less 
considerable  than  if  the  fradlure  had  been  produced  by  a  force 
immediately  applied  to  the  fradlured  part ;  for  the  aftion  of  the 
fraftured  extremities  on  the  surrounding  soft  parts  is  then  the  only 
cause  of  laceration  or  irritation.  But  a  force  which  fraftures  a 
bone  exadlly  on  the  part  which  it  strikes,  bends  it  to  the  opposite 
side,  and  wounds  or  lacerates  the  soft  parts.  Thus  a  blow  of  a 
stick  on  the  middle  part  of  the  clavicle,  where  the  fleshy  parts  give 
it  but  a  trifling  support,  bends  it  downward  and  backward,  and 
fradlures  it,  but  never  without  producing  a  greater  or  less  contu- 
sion, and  sometimes  a  contused  wound.  If  the  frafluring  force 
s/:rike  a  bone  equally  supported  in  all  its  parts,  the  frafture  will  be 
of  the  comminutive  species,  that  is,  in  several  fragments:  the 
contusion  is  always  great  in  such  cases. 


SECTION  in. 

Of  the  Signs  of  FraBures. 

The  signs  or  symptoms  of  fradlures  drawn  from  circumstances, 
^nd  established  by  reasoning,  are  never  conclusive.  The  pain, 
for  instance,  however  intense,  and  the  impossibility  of  moving 
the  limb,  may  be  occasioned  by  a  simple  contusion,  a  luxation,  and 
a  variety  of  other  causes.  The  immediate  signs  (the  natural  evi- 
dence of  which  precludes  reasoning),  generally  called  sensible 
ijjjnsj  s^ch,  for  instance,  as  an  alteration  in  the  form  of  tlie  limb. 


20  OF    THE    SIGNS    OF    FRACTURES. 

its  being  shortened,  and  the  crepitation  produced  by  the  fra£lu- 
red  surfaces  in  rubbing  one  against  the  other^  can  alone  give  any 
certainty  of  the  existence  of  a  fracture. 

When  the  Hmb  affe£led  is  found  shorter  than  the  other,  it  is 
necessary,  before  pronouncing  on  the  existence  of  a  frafture,  to 
be  certain  that  no  luxation  has  taken  place,  that  it  is  not  natural- 
ly so,  nor  in  consequence  of  a  former  fradlure  ill  set.  In  com- 
paring the  length  of  the  lower  extremities,  the  body  should  be 
placed,  so  as  that  the  anterior  and  superior  processes  of  the  ossa 
ilia  may  be  in  a  line  parallel  to  the  horizon;  for  if  one  of  them 
be  lower  than  the  other,  the  member  of  that  side  will  appear 
longer  than  the  other. 

Whoever  has  acquired  a  precise  knowledge  of  the  natural  cast 
and  conformation  of  our  members,  he  more  especially  who  has 
accurately  studied  the  relative  situation  of  the  processes  on  the 
extremities  of  the  bones,  will  quickly  perceive  any  change  indu- 
ced by-  a  fradlure.  Whenever,  in  consequence  of  a  blow  or  a 
fall,  a  member  becomes  concave  in  a  part  where  it  is  naturally 
convex  or  straight,  and  vice  ■versa;  this  change  of  form  and  di- 
rection must  be  attributed  tq  a  fracture,  ^yith  derangement  of  the 
fragments.  The  internal  side  of  the  great  toe,  when  the  foot 
bears  on  an  horizontal  plane,  ought  to  be  in  the  same  perpendi- 
cular line  with  the  inside  of  the  patella:  nothing  but  a  fradlure 
of  both  bones  of  the  leg  can  change  this  relative  position  of  these 
parts.  The  relative  position  of  the  condyles  of  the  humerus,  and 
of  the  apophyses  of  the  olecrarlon,  indicate  in  like  manner  the 
luxation  or  fradlure  of  the  humerus.  The  derangement  of  the 
fragments  may  sometimes  be  perceiyed  by  moving  the  fingers  on 
the  parts  of  the  bone  which  are  least  covered  by  the  integuments. 
This  sign  is  easily  .detected  in  the  fradtures  of  bones  which  are 
not  surrounded  by  much  flesh,  but  which  lie  almost  immediately 
under  the  skin:  such,  for  example,  are  those  of  the  lower  jaw 
and  the  clavicles. 

But  of  all  the  symptoms,  crepitation  is  the  most  general  and 
distindtive;  and  can  never  be  confounded  by  an  experienced 
pradtitioner  with  the  noise  produced  by  emphysema,  by  an  aque- 
ous effusion,  or  the  defedl  of  synovia.  In  order  to  know  if  this 
symptom  exists,  the  operator,  in  some  cases,  seizes  the  member 
between  both  his  hands,  and  presses  it  in  different  points  of  its 
length;  it  is  thus  that  the  fradlures  of  the  radius  are  ascertained, 
by  pressing  that  bone  from  the  external  side  to  the  internal.  In 
other  cases  the  operator  takes  a  fragment  in  each  hand,  and  by 
turning  their  extremities  in  opposite  diredlions,  produces  the 
crepitation,   if  the  fradlure  really  exists:   if  the  volume  of  the 


OF    THE    SIGNS    OF    FRACTURES.  It 

member  requires  it,  the  operator  causes  the  superior  fragment  to 
be  held  by  an  assistant,  whilst  he  moves  the  inferioron  it,  if  the 
fradlure  really  exists,  as  is  supposed  by  the  trial,  for  which  reason 
we  have  used  the  term  fragments,  as  if  it  really  did  exist. 

Although  in  the  greater  number  of  cases  it  be  easy  to  ascertain 
the  existence,  or  non-existence  of  a  fradlure,  by  the  foregoing 
signs;  yet  there  are  cases  in  which  certainty  is  very  difficult  to  be 
obtained.     This  difficulty  may  depend  on  several  causes. 

In  some  cases  the  bone  afFe<Si:ed  is  surrounded  by  such  a  depth 
of  fleshy  parts,  that  the  solution  of  continuity  is  almost  impossi- 
ble to  be  ascertained,  and  the  crepitation  is  very  indistinft.  If  in 
a  case  of  this  nature,  such,  for  instance,  as  in  some  fraftures  of  the 
neck  of  the  femur,  the  separation  of  the  fragments  one  from  the 
other  be  inconsiderable,  the  fradture  may  easily  remain  undisco- 
vered. The  fradture  of  one  of  the  bones  of  the  fore-arm  or  leg 
is  often  difficult  to  be  perceived,  because  the  other  bone  remain- 
ing whole,  preserves  the  form  of  the  member,  by  preventing 
any  considerable  separation  of  the  fragments. 

Finally,  if  the  surgeon  be  not  called  in,  until  a  compound  frac- 
ture has  been  still  further  complicated  by  an  inflammatory  swell- 
ing, it  will  be  extremely  difficult  to  ascertain  with  certainty  the 
existence  of  the  frafture;  and  thongh  that  knowledge  should  be 
obtained,  yet  it  will  be  prudent  to  await  the  abatement  of  the 
symptoms  before  any  attempt  be  made  to  set  the  frafture. 

When  every  possible  trial  has  failed,  and  doubts  still  remain  on 
the  existence  of  a  fra<5ture,  it  will  be  prudent  to  apply  the  ordi- 
nary apparatus  imbibed  with  some  resolvent  liquid;  after  the 
lapse  of  a  few  days,  the  apparatus  should  be  taken  off,  and  dis- 
continued if  it  be  found  that  no  frafture  exists,  or  re-applied,  in 
the  contrary  event;  at  all  events,  no  inconvenience  can  arise  from 
[ts  first  application. 


SECTION    IV. 
The  Prognosis  of  FraBures 

Is  different  according  to  the  bone  fradlured,  the  part  of  the 
bone  where  the  frafture  has  happened,  the  dired:ion  of  it,  and 
the  circumstances  which  attend  it. 

The  frafture  of  bones  which  are  superficial,  and  but  thinly  co- 
vered, is,  cateris  paribusy  less  dangerous  than  the  fracture  of 
bones  surrounded  by  many  and  strong  muscles.     Fra<5lures  of  the 


12  THE    PROCr^OSIS    OF    FRACTURES. 

superior  extremities  are  always  less  dangerous  than  those  of  the 
inferior  extremities.  The  fra£lure  of  the  middle  part  of  a  bone 
is  less  dangerous  than  that  of  its  extremities;  because  in  the 
former  case  it  happens  frequently,  that  the  cause  has  not  a6l- 
ed  immediately;  that  the  soft  parts  are  not  much  contused,  and 
the  inflammatory  swelling  is  less  to  be  apprehended.  Fraftures 
of  the  extremities  of  bones  may  produce  a  false  anchylosis  of  the 
neighbouring  articulation.  It  is  thus  that  in  the  frafture  of  the 
femur,  a  little  above  the  condyles,  the  congestion  extends  to  the 
knee,  and  occasions  a  stiffness,  which  it  is  difficult  to  remove : 
if  the  inflammation  extend  to  the  articulation,  the  consequence 
is  still  worse.  Finally,  the  splints  a£ling  only  on  one  of  the 
fragments,  render  their  disjundlion  very  easy.  Therefore,  the 
frafture  of  the  neck  of  the  femur  is  more  dangerous  than  that  of 
the  body  of  the  same  bone.  With  respe^l  to  the  dire£lion  of  the 
fradhire,  those  which  are  transverse  are  less  dangerous  than  the 
oblique;  and  the  greater  the  obliquity,  the  greater  the  danger, 
as  the  disjunction  is  on  that  account  more  easy;  for  which  reason, 
a  very  oblique  frafture  of  the  body  of  the  femur  is  esteemed  fully 
as  dangerous  as  that  of  its  neck. 

The  accidents  which  attend  a  fra£kure  add  more  or  less  to  its 
danger.  In  a  case  of  extreme  contusion,  attendant  on  a  commi- 
nutive  fraflure,  and  in  which  some  of  the  splinters  have  lacerated 
the  part  to  an  excessive  degree,  the  inflammation  may  be  so  vio- 
lent, as  that  mortification  will  ensue,  and  extend  from  the  mem- 
ber to  the  trunk,  and  kill  the  patient  in  a  very  few  days.  In  ge- 
neral, fradlures  complicated  with  contusion  and  wound,  are  more 
dangerous  in  the  inferior  than  in  the  superior  extremities. 

Finally,  the  prognosis  v/ill  be  more  or  less  unfavourable,  ac- 
cording to  the  health  and  age  of  the  individual.  In  a  debilitated 
old  man,  a  fradlure  is  more  dangerous,  than  in  a  person  in  the 
flower  of  youth  and  health.  There  are  certain  dispositions  of 
the  body,  which  influence  very  much  the  prognosis.  Scurvy, 
for  instance,  retards  to  such  a  degree  the  formation  of  the  callus, 
that,  joined  with  old  age,  it  may  prevent  it  entirely.  The  state 
of  pregnancy,  notwithstanding  what  authors  have  said  of  it,  does 
rot  retard  the  consolidation  of  a  fra<^ure,  at  least  not  to  any  sen- 
sible degree. 


OF    THE    TREATMENT    OF    FRACTURES.  23 

SECTION    V. 

Of  the  Treatment  of  FraElures. 

The  first  and  principal  indication  in  a  fradlure,  without  de- 
rangement of  the  fragments,  is  to  retain  the  fragments  in  their 
natural  situation,  to  prevent  the  bad  symptoms  which  generally 
follow,  or  combat  them  if  they  have  already  taken  place;  but  if 
there  be  derangement,  as  most  generally  happens,  it  will  be  ne- 
cessary, in  the  first  place,  to  set  the  bone,  that  is,  to  restore  the 
fragments  to  their  natural  situation. 

The  manner  of  setting  a  fractured  bone  varies,  according  to 
the  nature  and  species  of  the  fracture;  and  the  precept  is  not 
perfe6tly  correft,  which  says,  that  in  every  fradlure,  extension, 
counter-extension,  and  coaptation  are  necessary;  because  in  seve- 
ral cases  the  extension  and  counter- extension  are  perfedlly  useless^ 
as,  for  instance,  in  the  fractures  of  the  patella  and  olecranon,  in 
which  the  fragments  separate  in  opposite  diredlions.  It  is  mere- 
ly necessary  for  their  redudlion  to  push  the  fragments  one  tcv- 
wards  the  other,  having  first  extended  the  leg  or  fore-arm,  in 
order  to  relax  the  muscles  which  have  their  insertion  in  the  part 
affefted.  In  the  derangement  in  the  dire<f!:ion  of  the  diameter  of 
the  bone,  only  a  very  slight  degree  of  extension  will  be  necessa- 
ry, in  order  to  diminish  the  friction  of  the  fractured  surfaces, 
which  move  in  contrary  directions.  Extension  and  counter-ex- 
tension are  still  useless,  when  the  displaced  fragments  form  an 
angle  one  with  the  other;  for  it  will  suffice  to  place  the  member 
on  an  horizontal  plane,  in  order  to  reduce  the  member  to  its  na- 
tural dire£tion.  The  derangement  of  the  circumference  is  alike 
easily  reduced  by  a  rotatory  motion  given  to  the  lower  fragment, 
in  the  direction  contrary  to  that  which  it  took  in  quitting  its  na- 
tural situation. 

Extension  and  counter-extension  are  not  therefore  of  any  very 
evident  utility,  except  in  the  derangement  in  the  diredtion  of  the 
axis  of  the  bone,  in  which  both  fragments  mutually  pass  one 
another. 

Extension  is  the  force  exerted  on  the  lower  fragment,  in  order 
to  bring  its  superior  extremity  lower  than  the  inferior  extremity 
of  the  superior  fratftured  portion:  counter-extension  is  a  resisting 
force,  which  prevents  the  whole  limb,  or  even  the  bodv,  from 
obeying  the  force  of  extension.  The  hands  of  intelligent  assist- 
ants are  always  best  for  both  these  purposes;  it  is  but  very  sel- 
dom that  anv  advantage  can  be  derived  from  the  use  cf  more 


24        OF  THE  TREATMENT  OF  FRACTURES. 

powerful  means,  which  by  their  excessive  force  extend  too  vio- 
lently the  muscles  and  soft  parts,  occasion  much  pain,  and  pro- 
duce spasmodic  contraction  of  the  muscles,  which  resist  always 
in  proportion  to  the  force  of  extension,  and  on  that  account  ren- 
der it  most  frequently  of  no  efFecl. 

The  pra<5lice  was  formerly  to  apply  the  force  of  extension  on 
the  inferior  fragment,  and  that  of  the  counter-extension  on  the 
superior;  but  exclusive  of  the  difliculty  of  seizing  the  two  frag- 
ments, which  difficulty  is  in  some  cases  insurmountable,  as  in  the 
fracture  of  the  neck  of  the  femur;  there  is,  besides,  a  great  dis- 
advantage attending  it  when  practicable,  namely,  the  spasmodic 
contraction  of  the  muscles  which  snrround  the  fracture,  caused 
by  the  irritation  and  violence  which  they  suffer. 

It  is  therefore  better  to  make  the  extension  on  the  lower  part  of 
the  limb,  or  on  the  bone  which  articulates  with  the  inferior  frag- 
ment, and  the  counter-extension  or  that  which  articulates  with  the 
superior.  In  a  fracture  of  the  leg,  for  instance,  the  extending  force 
should  act  on  the  foot,  and  the  counter-extending  on  the  thigh; 
whilst  in  that  of  the  thigh,  these  opposing  forces  should  be  applied 
to  the  leg  and  pelvis.  There  Is  nothing  to  be  said  as  to  the  degree 
of  forc€  to  be  employed,  because  that  must  vary  according  to  the 
extent  of  the  derangement,  and  the  number  and  strength  of  the 
muscles  which  have  produced  it.  The  direClion  in  which  these 
forces  ought  to  aCt,  is  that  which  the  inferior  fragment  pursued 
in  taking  its  unnatural  position;  but  this  applies  alone  to  the  force 
of  extension,  because  the  opposing  force  is  a  mere  resistance. 
Thus,  if,  in  a  fracture  of  the  thigh,  the  lower  fragment  has 
ascended  on  the  internal  side  of  the  superior,  the  foot  and  knee 
will  be  turned  a  little  externally;  and  the  extension  ought  there- 
fore to  be  directed  at  first  downward,  and  outwards;  afterwards, 
in  proportion  as  the  limb  recovers  its  proper  direction,  the  frag- 
ment ought  to  be  drawn  into  its  natural  position.  The  assistants 
employed  in  this  operation  should  be  very  intelligent,  because, 
when  extension  is  well  made,  coaptation  becomes  very  easy.  It 
is  much  easier  to  set  a  fraCture,  than  to  keep  the  bones  in  their 
place;  in  which  it  ditters  from  luxation,  which  is  difBcuk  to  be 
reduced,  but  easily  prevented  from  relapsing.  The  means  com- 
monly in  use  to  maintain  the  portions  of  a  fractured  bone  in  exaCt 
contact,  and  the  member  perfeCtly  motionless  during  the  time 
necessary  fv)r  the  formation  of  the  callus,  are  reducible  to  a  pro- 
per position,  repose,  bandages,  and  other  kinds  of  apparatus, 
such  zs  famns^  faux-f a f ions,  compresses,  stuffing,  splints,  machines 
of  various  constructions,  and  the  means  of  efFeCting  perpetual 
extension.    We  shall  consider  each  of  these  in  detail,  successively. 


OF  THE  TREATMENT  OF  FRACTURES.  "^■•"'^  25 

In  the  first  place,  a  situation  is  to  be  given  to  the  limb,  in  which 
it  riiay  continue  as  long  as  the  afFe(fliort  lasts;  for  that  purpoise  it 
ought  to  be  placed  on  a  horizontal  plane,  so  disposed,  that  the 
intervals  between  it  and  certain  parts  of  the  limb  shall  be  filled 
up,  in  order  that  every  part  of  it  may  be  equally  supported. 
This  horizontal  support  ought  to  be  capible  of  making  a  conside- 
rable resistance;  without,  however,  being  hard  enough  to  give 
any  uneasiness  Or  pain.  For  this  purpose  a  mattress  of  hair  seems 
preferable  to  any  other;  biecause  one  of  wool  oi:  feathers  yields 
too  much  to  the  weight  of  the  limb  and  apparatus.   . 

Surgeons  were  for  some  time  divided  in  their  opinions  oh  the 
best  position.  Pott  has  advised  the  limb  to  be  kept  half  bent; 
which  position,  he  says,  has  the  advantage  of  giving  to  the  mus- 
cles which  surround  an  articulation,  an  equal  and  moderate  de- 
gree of  tension ;  whereas,  if  the  member  be  placed  straight,  some 
of  thiese  muscles  will  be  much  extended,  whilst  others  are  as  much 
relaxed.  The  latter  position,  however,  is  that  ^vhich  it  general- 
ly preferred. 

Demi-flexion  is  th6  most  natural  position}  it  is  that  which  our 
limbs  spontaneously  assumie  during  sleep,  and  has  for  that  reason 
been  recommended  both  by  Galen  and  Hippocraties:  but  a  limb 
half  bent,  is  not  solidly  fixed,  and  changes  frequently  its  situati- 
on, by  numerous  involuntary  motions,  which  may  be  occasioned 
by  dreams  or  pain.  This  position  has,  besides,  this  great  incon- 
venience, that  during  the  treatment,  the  length  of  the  fra^red 
limb  cannot  be  compared  with  that  of  the  opposite  side,  nor  can 
it  therefore  be  known  if  the  frafture  be  well  set,  and  the  appara- 
tus well  applied;  and  in  truth,  demi-flexion  becomes  at  length  as 
painful  as  the  extension  at  full  length.  The  advantages  of  the 
former  have  therefore  been  a  Httle  exaggerated  by  Pott,  as  well 
as  the  disadvantages  of  the  latter,  which  alone  is  now  used  in 
France,  and  generally  adopted  in  foreign  coiintries. 

In  whatever  position  the  limb  is  placed,  most  perfe£l  repose  is 
absolutely  necessary,  particularly  in  the  commencement;  for  if 
the  fraftured  pieces  be  moved  one  upon  the  other,  nature  cannot 
efFe£t  their  reunion,  which  would  therefore  be  retarded  or  total- 
ly prevented,  if  the  frifWon  of  the  surfaces  were  frequent,  and 
suffered  to  continue  long;  in  which  case  an  articulation  would  be 
formed  in  the  situation  of  the  frafture,  and  consequently  the  pa- 
tient remain  disabled  for  ever  after. 

It  is  necessary  to  apply  proper  bandages  and  other  apparatus, 

without  which  the  position  given  to  the  member,  however  good, 

would  be  insufficient;   because,  without  these,  the  involuntary 

motions  which  are  inevitable,  those  which  are  produced  by  pain, 

4 


26  OF  THE  TREATMENT  OF  FRACTURLS. 

and  those  again  which  are  rendered  necessary  by  our  natural  v/aftts^ 
would  certainly,  without  that  precaution,  disturb  more  or  less  thi 
just  relative  position  of  the  fraflured  pieces,  which  even  the  de- 
pressions and  inequality  of  the  bed  would  affect,  if  not  guarded 
against. 

Bandages  had  been  for  a  long  time  considered  as  the  most  ef- 
fedtual  means  of  retaining  the  fragments  in  just  contact;  but  it  is 
easy  to  prove,  that  bandages,  however  contrived,  can  have  but 
little,  or  absolutely  no  effedt  for  this  purpose.  We  shall  examine 
successively,  those  which  have  been  in  use,  viz.  the  roller,  eight- 
een tailed  bandage,  and  that  of  Scultet,  composed  of  separate 
pieces. 

The  first  ought  to  be  long  enough  to  cover  the  whole  limb, 
three  inches  broad,  and  rolled  Up  in  one.  It  is  applied,  by  draw- 
ing first  three  folds  of  it  over  the  fractured  parts;  it  is  then  mad^ 
to  descend  to  the  extremity  of  the  limb,  in  such  a  manner,  as 
that  each  roll  shall  cover  a  part  of  the  preceding;  it  is  made  to 
ascend  again  in  like  manner  to  the  situation  of  the  fracture,  when 
three  folds  more  of  it  are  applied;  after  which  the  superior  part 
of  the  limb  is  covered,  in  the  same  manner  as  the  inferior;  and 
if  the  bandage  be  long  enough,  it  may  be  again  rolled  on  down- 
wards. Let  us  suppose  this  bandage  applied  to  a  fra(Sture  of  the 
middle  part  of  the  femur,  or  humerus:  it  is  plain  that  those  parts 
of  it  which  are  applied  on  one  of  the  fragments  alone,  are  abso* 
lutely  of  no  effe6l,  and  that  that  part  of  it  only  which  comprehends 
both  fragments,  can  contribute  to  keep  them  in  contact.  But  in 
order  to  understand  how  extremely  trifling  its  effedl  must  be,  it 
is  sufficient  to  remark,  that,  as  it  is  but  three  inches  broad,  it  can 
include  only  an  inch  and  a  half  of  each  fractured  portion;  and 
that  this  very  trifling  power  is  stiil  farther  diminished,  by  the 
greater  or  less  quantity  of  soft  parts  which  intercept  its  action. 

In  this  respect,  the  eighteen-tailed  bandage  is  preferable  to  the 
former.  It  is  composed  of  three  pieces  of  linen,  equal  in  length  to 
the  member,  and  broad  enough  to  pass  once  and  a  half  round  the 
limb.  These  pieces  are  sewed  together  by  a  seam,  which  runs  from 
one  extremity  to  the  other;  and  afterv/ards,  cut  each  into  three; 
so  that  the  whole  is  composed  of  eighteen  pieces,  nine  at  each 
end.  The  bandage  thus  composed,  being  moistened,  is  extend- 
ed under  the  limb,  and  the  middle  piece  on  each  side  is  first  ap- 
plied on  the  situation  of  the  fracture,  then  the  superior  ones, 
and  afterwards  the  inferior,  and  so  successively  with  the  middle 
and  inferior  pieces.  The  six  middle  pieces  of  this  bandage  act 
with  more  efficacy  on  the  frafcure,  than  the  folds  of  the  former 
bandage;  because  being  much  broader,  they  encompass  a  greater 


OF    THE    TREATMENT    OF    FRACTURES.  27 

part  of  it.  It  has  this  other  advantage  over  the  former  bandage, 
that  its  appHcation  is  easier,  and  does  not  require  that  the  Umb 
should  be  kept  raised,  nor  exposed  to  many  motions,  which  are 
always  hurtful. 

Scultet's  bandage  is  composed  of  as  many  pieces  of  three  in- 
ches broad  each,  as  are  necessary  to  cover  the  whole  length  of 
the  member,  in  lapping  two  thirds  over  one  another.  It  is  com- 
posed of  a  piece  of  linen,  of  three  times  the  length  of  the 
limb,  and  broad  enough  to  pass  once  and  a  half  round  the  limbj 
it  is  to  be  cut  according  to  its  breadth,  in  pieces  of  three  inches 
broad  each:  this  done,  the  pieces  are  extended  under  the  mem- 
ber, one  covering  three?  parts  of  the  other  in  proceeding  from 
the  inferior  part.  This  bandage  like  the  two  former,,  acts  only 
by  the  pieces  which  encompass  at  once  the  contiguous  parts  of 
the  two  fragments;  it  is  preferable  however  in  ih^  following  re- 
spefts. 

It  contributes  as  much  as  the  others  to  rnaint^in  thje  fragments 
in  their  just  position;  it  compresses  sufEciently  the  member,  and 
prevents  any  oedema j  it  is  in  this  respect  preferable  to  the 
eighteen-tailed  bandage,  the  parts  of  which  not  passing  one  on 
the  other,  do  not  compress  all  the  parts  equally;  whence  it  hap- 
pens, that  those  parts  whiclj  .correspond  to  the  edges  of  the 
pieces  become  oedematous. 

This  bandage  can  be  taken  off,  and  re-applied,  without  mo- 
ving the  limb,  in  which  it  is  far  preferable  to  the  first  mentioned 
bandage,  the  disadyan.tage  of  which  in  that  respeft  has  been  al- 
ready pointed  out.  The  eighteen-tailed  bandage  cannot  be  so 
conveniently  renewed  as  that  of  Scultet,  because,  when  any  part 
of  it  is  soiled  by  purulent  matter,  or  any  other  cause,  it  is  neces.- 
sary  to  remove  it  entirely,  and  apply  another;  whereas  any  par- 
ticular piece  of  that  of  Scultet  may  be  changed,  and  a  new  one 
applied  in  its  place,  which  may  be  done  without  moving  the 
jmember,  by  fastening  the  new  one  to  the  extremity  of  the  old,  and 
drawing  it  into  its  proper  situation  at  the  same  time  that  this  latter 
is  taken  away.  It  ought,  therefore,  to  be  preferred  to  the  two 
former,  except  in  cases  of  simple  fra^lure  of  the  superior  ex- 
Iremities. 

Although  bandages  may  be  of  no  great  use  for  keeping  the 
broken  pieces  in  their  proper  position,  yet  they  are  useful  for 
supporting  topical  applications,  and  preventing  oedema  of  the 
iimb;  they  are  still  further  useful  in  benumbing  the  muscles,  and 
in  preventing  their  contraftlon. 

The  faux-famu  is  a  cloth  rolled  on  itself,  and  differs  from  the 
fanon  in  this,  that  in  the  latter  there  is  enclosed  a  piece  of  wood. 


l8       OP  THE  TREATMENT  OF  FRACTURES 

They  are  applied  on  the  internal  and  external  sides  of  the  limbj 
but  our  limbs,  like  the  fansns^  being  nearly  round,  these  latter 
come  in  contaft  with  the  limb  but  by  a  very  narrow  surface,  so 
that  in  tightening  the  strings  by  which  they  are  secured,  they  are 
liable  to  slide  forwa^"d  or  backward;  in  which  cases  their  aftion  is 
frustrated,  i^o  effeft  produced,  and  the  fradtured  portions  sepa- 
rate without  any  difficulty. 

Splints  are  much  surer  means;  they  may  be  formed  of  different 
substances,  and  their  shape  and  length  accommodated  to  those  of 
the  limb  in  which  the  fradhire  has  taken  place. 

Splints  made  of  pasteboard  were  formerly  in  use,  which  being 
W€|t  \yere  easily  adapted  to  the  form  of  the  member,  and  in  dry- 
ing were  pioulded  to  it.  They  have  been  also  made  of  the  bark 
of  trees,  but  the  brittleness  of  these  caused  them  to  be  laid  aside. 
At  present,  \food  or  tin  are  the  only  materials  of  which  splints 
are  made:  they  are  usually  thin  and  narrow,  and  rounded  at 
tKeir  extremities:  their  length  must  be  deteripined  by  circun>- 
stances.  Those  of  tin  are  extremely  proper  for  simple  frji£hires 
of  the  superior  extremities;  their  flexibility  admitting  them  to  be 
adapted  exactly  to  the  form  of  the  member.  In  case  of  not  ha- 
ving them,  their  want  may  be  supplied  by  thin  laths  of  flexible 
wood,  susceptible  of  being  moulded  into  the  shape  of  a  trough. 
In  general,  splints  for  the  superior  extremities  ought  to  equal  the 
fra£hjred  bone  in  length.  In  fra£tures  of  the  arm,  the  splint 
which  is  placed  on  the  for^  part,  ought  to  be  a  little  shortened, 
and  not  to  descend  to  the  bend  of  the  arm,  in  order  that  its  de- 
mi-flexion  may  not  be  prevented. 

The  splints  designed  for  the  inferior  extremities  ought  to  be 
strong,  thick  and  flexible,  and  longer  than  the  member.  For  a 
fracture  of  the  thigh,  the  external  splint  ought  to  extend  from 
the  superior  part  of  the  os  ilium,  to  a  little  lower  than  the  sole  of 
the  foot;  the  internal  should  equally  descend  from  the  upper  and 
internal  part  of  the  thigh  to  a  little  below  the  foot,  and  the  an- 
terior from  the  groin  to  the  superior  part  of  the  leg.  In  frac- 
tures of  the  leg,  the  internal  and  external  splints  ought  to  ascend 
above  the  knee,  and  descend  below  tlie  foot. 

In  order  to  understand  how  the  splints  a£t,  it  is  necessary  to 
recoUedt  what  has  already  been  said  of  the  derangement  of  frag- 
ments; it  is  clear  they  prevent  that  in  the  direction  of  the  diar 
meter  of  the  bone,  by  being  in  opposition  one  to  the  other, 
on  every  side  of  the  bone,  and  by  resisting  therefore  any  force 
which  might  tend  to  move  either  fragment  internally  or  exter- 
nally, forward  or  backward.     In  fractures  of  the  inferior  extre- 


OF  THE  TREATMENT  OF  FRACTURES.       29 

fahy,  no  posterior  splint  is  necessary,  because  its  place  is  supplied 
by  the  plane  on  which  the  member  rests. 

Splints  prevent  also  the  angular  derangement  of  the  fragments, 
by  supporting  each  of  them  in  the  whole  length  of  the  member. 
They  prevent  also  the  derangement  in  the  circumference;  but  in 
prder  to  do  so,  they  must  aft  on  that  part  of  the  limb  which  is 
articulated  with  the  lower  fragment.  For  in  a  fradlure  of  the 
femur,  for  instance,  if  the  splints  do  not  descend  below  the  thigh 
there  is  nothing  to  prevent  the  weight  of  the  foot  or  leg,  or  that 
of  the  bed-cloaths,  from  turning  them  either  inward  or  outward, 
and  with  them  the  lower  fragment. 

The  derangement  in  these  three  last  mentioned  direflions  is 
more  easily  prevented  by  splints,  than  that  in  the  direftion  of  the 
axis,  or  by  chevauchement.  If  the  frafture  be  transverse,  the 
splints  prevent  even  this  latter  kind  of  derangement,  because 
they  obviate  that  in  the  direction  of  the  diameter  of  the  bone, 
which  must  i^ecessarily  precede  it.  But,  if  the  fracture  be  ob- 
lique, that  is,  with  sloped  surfaces,  the  fragments  do  not  then 
oppose  a  sufficient  mutual  resistance,  but  slide  on  one  another 
with  a  facility  proportional  to  the  obliquity  of  the  fracture. 

In  such  a  case,  the  splints  can  oppose  the  derangement  only  by 
the  degree  of  compression  which  they  make  on  the  whole  length 
of  each  fractured  portion;  but  if  the  fracture  be  very  oblique,  the 
surfaces  smooth,  and  the  part  surrounded  by  strong  muscles,  this 
derangement  will  probably  take  place.  Thus  it  is  found  by  expe- 
rience to  be  almost  impossible  to  maintain  properly  adjusted,  an 
qblique  fracture  of  the  body  of  the  femur,  by  the  aid  of  splints 
alone.  It  is  equally  difficult  to  remedy  by  their  means  oblique 
fractures  of  the  clavicle;  because  they  cannot  be  applied  on  every 
side  of  that  bone. 

The  impossibility  qf  obtaining,  in  certain  cases,  a  cure  exempt 
from  all  deformity,  by  ordinary  means,  has  made  surgeons  recur 
to  another  apparatus,  which,  by  drawing  continually  the  two  pie- 
ces in  opposite  directions,  prevents  them  from  repassing  one  on 
the  other,  and  keeps  the  fractured  surfaces  in  just  contact  all  the 
time  necessary  for  their  consolidation  ;  this  method  has  been 
termed  perpetual  extension. 

This  apparatus  should  not  be  applied  before  the  irritation  and 
spasm  of  the  muscles  are  completely  removed.  It  prevents  the 
muscular  fibres  from  being  too  forcibly  stretched  or  elongated  be- 
yond their  natural  extensibility  ;  it  supplies  the  place  of  the  bone, 
which,    before  the  frafture,   regulated  the   contraftion   of  the 


3©       OF  THE  TREATMENT  OF  FRACTURES, 

muscles.     Its  application  may  be  submitted  to  some  general  rules, 
which  I  shall  copy  here  from  a  work  on  that  subjeft.* 


RULE   I. 

To  apply  the  extending  Force  on  the  Parts  of  the  Members  inferior 
and  superior  to  the  fraBured  Bone. 

The  extending  and  counter-extending  forces  ought  not  to  be 
applied  immediately  on  the  fractured  bone,  but  on  that  which 
articulates  with  the  inferior  fragment,  for  the  extension;  and 
for  counter-extension,  on  that  which  articulates  with  the  superior. 
Continued  extension  not  differing  from  simple  extension  and 
.counter-extension,  except  in  its  being  continue^,  the  same  rea- 
soning applies  to  both  cases. 


RULE    II. 

To  aEi  on  as  great  a  Superficies  as  possible. 

In  order  to  fulfil  this  condition,  the  bandages  and  other  pieces 
of  the  apparatus,  ought  to  be  as  broad  as  possible.  The  etfe£t 
which  external  causes  have  on  our  bodies,  is  small  in  proportion 
to  the  extent  of  the  surfaces  on  which  they  a£l;  because  the  ac- 
tion is  then  supported  by  a  greater  number  of  parts.  A  thin  and 
narrow  bandage  of  linen  folds  on  itself  quickly,  and  becomes  a 
hard  cord,  which  causes  a  distension  of  the  vessels  of  the  inferior 
part  of  the  member,  by  obstructing  the  return  of  the  lymph  and 
venous  blood. 


RULE  in. 

To  give  to  the  extending  Power  a  Direction  parallel  to  the  Axis  of 

the  Bone. 

The  science  of  mechanics  teaches  us  that  the  aclion  of  a  force 
on  a  lever  is  decomposed,  if  its  direction  be  oblique  to  the  lever, 


*  Anatomio-surgical    Dissertation   on  Fia€lures  of  the  Neck  of  t\tz  FeiTiur,  br 
A.  Richerand,  oftivo,  Paris,  year  7. 


OF  THE  TREATMENT  CF  FRACTURES.       Jl 

one  part  of  it  a£ling  in  that  diredlion,  and  the  other  in  that  of  the 
lever;  that  is,  in  geometrical  terms,  the  force  acling  on  the  lever 
will  be  to  the  vrhole  force  as  the  angle,  formed  by  its  direction 
with  the  lever,  is  to  a  right  angle.  It  is  easy  to  perceive  that  the 
part  of  this  force  which  is  not  employed  to  effect  the  desired  pur- 
pose, must  counteract  the  proposed  end,  by  causing  pain,  and 
uselessly  compressing  the  parts. 


RULE   IV. 

The  Extension    ought  to  he  as  gradual  as  poss'ibUy  operating  sloivlyt 
and  by  Degrees. 

Animal  parts  which  yield  to  long  continued  and  insensible  ac- 
tion of  exterior  causes,  resist  any  violent  and  sudden  effort,  and 
revolt  against  it,  as  it  were,  with  all  their  force:  thus  the  slower 
and  the  less  rapid  the  extension,  the  more  easily  do  the  parts  of 
our  body  yield. 

Continued  extension  does  not  exclude  the  ordinary  apparatus, 
but  is  additional  to  it. 

As  every  part  of  the  surface  of  our  limbs  does  not  lie  in  the 
same  plane,  that  is,  as  our  limbs  are  prominent  in  some  parts,  and 
depressed  in  others,  and  therefore  liable  to  be  hurt  and  bruised 
by  hard,  straight,  and  inflexible  splints,  even  to  the  degree  of 
producing  gangrene,  some  means  of  remedying  these  disadvan- 
tages, and  preventing  these  bad  e£Fe£ts,  were  naturally  recurred 
to.  For  this  purpose  the  different  depressions  of  the  limb  are 
filled  with  lint,  rags  of  eld  linen,  compresses,  or,  what  is  still 
better,  with  little  bags  of  the  chaff  of  oats  5  the  facility,  which 
these  latter  offer,  of  moving  the  chaff  from  one  part  to  another, 
as  well  as  their  soft  and  equable  pressure,  give  them  an  evident 
advantage:  by  these  means  the  pressure  becomes  equal  on  every 
part  of  the  length  of  the  member.  Finally  it  is  not  superfluous 
to  remark,  that  tape  ought  to  be  preferred  to  strips  of  linen, 
which  knot  with  difficulty,  particularly  when  wet,  for  the  pur- 
pose of  binding  externally  the  whole  apparatus.  The  number 
of  these  tape  strings  must  be  proportioned  to  the  length  of  the 
member;  as  must  the  length  of  the  bags  of  chaff  to  that  of  the 
splints,  the  action  of  which  they  are  intended  to  moderate. 

We  shall  in  the  next  place  examine  what  is  required  by  the 
third  indication  of  frafture.''  that  is,  to  prevent  the  complications 
which  may  succeed  to  it,  and  to  remedy  them  when  they  have 
Teally  taken  place. 


32       OF  THE  TREATMENT  OF  FRACTURES. 

In  every  frafture,  with  the  exception  of  those  of  the  sUperiof 
extremities,  which  are  simple,  the  patient  ought  to  be  confined 
to  a  low  regimen  for  the  first  four  or  five  days :  more  or  less  blood 
should  be  drawn,  if  it  be  not  contra-indicated  by  extreme  old  age, 
or  great  debility.  No  greasy  irritating  plasters,  of  which  quacks 
make  so  much  use,  such  for  instance,  as  the  plaster  of  Cyroane, 
are  to  be  employed;  but  in  their  stead,  it  will  be  sufficient  mere- 
ly to  cover  the  limb  with  several  folds  of  compresses  soaked  in 
camphorated  spirit,  or  a  solution  of  the  acetate  of  lead,  or  any 
other  repellent  liquid,  with  which  also  the  other  parts  of  the 
bandage  should  be  moistened.  A  solution  of  common  salt  is  to 
be  avoided,  because  that  salt  would  quickly  crystallize,  hardening 
thereby  the  dilfferent  pieces  of  the  bandage,  and  giving  them  a 
stiffiiess  unpleasant  to  the  patient.  The  bowels  should  be  kept 
open  by  gentle  laxatives;  such  as  veal  broth,  whey  acidulated 
with  tamarinds,  &c.  When  the  lapse  of  a  few  days  renders  this 
regimen  no  longer  necessary,  the  patient  should  be  allowed  a  mo- 
derate quantity  of  very  nutritive  and  easily  digestible  food;  for  it 
would  be  not  only  useless,  but  dangerous  to  prolong  the  low  regi- 
men, in  the  case  of  a  simple  fra£lure,  which  does  not  sensibly 
disturb  the  functions,  and  which  requires  for  its  consolidation,  a 
degree  of  vital  energy  in  the  solids,  which  a  too  sparing  diet  would 
enfeeble. 

We  shall  not  here  amuse  our  readers  with  the  different  means 
recommended  to  increase  the  viscidity  of  the  blood,  in.  order 
thereby  to  accelerate  the  consolidation  of  the  frafture;  but  pro- 
ceed to  consider  the  treatment  adapted  to  compound  fraftures: 
this  treatment  must  vary  according  to  the  nature  of  the  compli- 
cation. 

Under  this  head,  we  have  to  consider,  in  the  first  place,  the 
very  difficult,  but  also  very  rare  case  of  fra^ure  accompanied 
by  luxation.  When  this  takes  place,  the  Itixation  must  have  pre- 
ceded the  frafture;  for  a  bone  once  fra«^bired,  is  no  longer  capa- 
ble of  luxation.  The  principal  question  is,  to  which  of  the  acci- 
dents shall  we  in  the  first  place  direifl  our  attention  ?  Some  are  of 
opinion,  that  the  dislocated  fragment  should  be  first  replaced  in 
its  natural  articulation ;  others,  on  the  contrary,  recommend  to 
await  the  consolidation  of  the  fra£ture,  before  any  attempt  be 
made  to  remedy  the  luxation:  but  we  adopt,  most  decidedly,  the 
first  opinion;  for  during  the  treatment  of  the  fradlure,  the  soft 
parts  acquire  a  stiffness,  and  become  so  habituated,  if  the  expres- 
sion may  be  allowed,  to  their  new  situation,  that  the  dislocation 
cannot,  without  great  difficulty,  be  remedied  ;  but  if  in  order  to 
effedt  it,  violent  eflbrts  and  straining  are  unavoidable,  it  will  in 


OF  THE  TREAtMENT  OF  FRACTURES.       33 

that  case  be  better  to  set  the  fra£bire  first ;  and  as  soon  as  the  con- 
solidation is  a  little  advanced,  habituate  the  member  to  certain 
gentle  motions,  in  order  to  preserve  the  suppleness  of  the  liga- 
ments, which  will  facilitate  the  cure  of  the  dislocation,  when  the 
complete  consolidation  of  the  frafture  allows  it  to  be  attempted. 

When  the  soft  parts  of  a  fractured  limb  are  violently  contused, 
but  without  external  wound,  the  apparatus  should  not  be  too 
touch  braced;  and  Scultet's  bandage  should  in  such  cases  be  al- 
ways used,  even  though  the  frafture  be  in  the  superior  extremity. 
A  large  portion  of  blood  should  be  immediately  drawn,  and  the 
blood-letting  repeated,  except  the  patient  has  the  stomach  full, 
as  is  generally  the  case  in  hospitals;  for  the  common  people  are 
usually  brought  there  in  a  state  of  intoxication.  The  bandages 
must  be  taken  off  on  the  following  day;  this  rule  is  without  ex- 
ception; the  negleft  of  it  has  caused  a  mortification  of  the  limb, 
which  takes  place  by  the  bandages  becoming  too  tight,  in  conse- 
quence of  the  swelling  which  ensues,  and  by  the  consequent 
stoppage  of  the  circulation.  On  this  first  removal  of  the  banda- 
ges, the  member  is  generally  found  hard,  tumefied,  tense,  and 
the  patient  complains  of  great  pain.  In  which  case  the  fra£lured 
part  is  to  be  covered  with  emollient  poultices,  over  which  the 
proper  bandage  may  be  applied,  and  the  splints  moderately  braced. 
In  cases  of  extreme  contusion,  without  a  wound  of  the  integu- 
ments, the  tension  and  inflammatory  swelling  may  become  so  in- 
tense, as  to  cause  the  cuticle  to  rise  in  little  blister-like  vesicles 
filled  with  a  limpid  serum,  very  different  from  that  blackish  serum 
which  fills  the  vesicles  attendant  on  mortification.  These  vesi- 
cles should  be  opened  without  detaching  the  cuticle,  and  the 
small  openings  covered  with  linen  on  which  some  cerate  has  been 
spread.  By  these  simple  means  the  surgeon  has  the  satisfacSVion 
of  seeing  the  inflammation,  and  all  its  menacing  consequences, 
subside  in  a  few  days,  leaving  merely  a  slight  degree  of  ecchymo- 
sis,  which  disappears  in  a  short  time.  The  poultices  are  then 
discontinued,  the  patient  is  allowed  a  nourishing  diet,  the  splints 
are  braced  to  the  ordinary  degree,  and  the  treatment  is  after- 
wards the  same  as  that  of  a  simple  fradture. 

If  a  vessel  of  a  certain  magnitude  is  opened  by  a  frafture,  and 
the  cellular  texture  of  the  limb  becomes  distended  by  the  effused 
blood,  which  may  be  perceived  by  the  tumefaction,  and  black  or 
livid  colour  of  the  Aember,  the  surgeon  ought,  without  hesita- 
tion, to  make  an  incision  in  the  part  over  the  artery,  and  apply  on 
it  t\vo  ligatures,  one  above  the  other,  below  the  wounded  part. 
J.  L.  Petit  relates  a  case  of  a  false  primative  aneurism,  produced 
by  the  laceration  of  the  anterior  tibial  artery  in  a  fratture  of  th» 
5 


34  OF    THE    TREATMENT    OF    FRACTURES'. 

leg.  It  is  possible  too,  that  the  laceration  of  a  vein  may  occasfoti! 
an  effusion  of  blood,  easy  to  be  mistaken  for  a  false  primitive' 
aneurism.  Such,  probably,  was  the  case  of  the  female  of  Gros^ 
Caillou,  who  fradtured  her  leg  with  a  wound  by  falling  from  her 
cart.  In  three  or  four  days  after  entering  the  hospital  De  la 
Charitey  the  leg  swelled  enormously,  the  skin'  became  of  a  vio- 
lent colour,  and  of.  a  marbled  appearance;  and  there  issued  from 
the  wound  but  a  small  quantity  of  blood.  The  lesion  of  the  an- 
terior tibial  artery  was  suspefted  ;  the  taking  of  it  up  was  not, 
however,  attempted :  the  patient  was  bled,  emollient  poultices 
were  applied,  and  by  these  simple  means  the  tension  quickly  di- 
minished, and  the  effusion  and  distension  vanished;  a  considera- 
ble degree  of  ecchymosis,  however,  remained,  which  gradually 
disappeared. 

The  wounds  which  render  a  fracture  compound  may  be  owing 
to  the  cause  of  the  fracture,  or  may  be  occasioned  by  the  penetra- 
tion of  the  point  of  one  of  the  fragments  though  the  integuments. 
In  the  latter  case,  the  wound  should  be  enlarged  by  a  bold  laci^ 
sion,  and  the  projedting  fragment  pushed  into  its  proper  situation. 
But  if  the  projefting  part  be  of  a  considerable  length;  if  the  mus- 
cles contract  spasmodically,  and  much  exertion  and  straining  be 
necessary  to  reduce  it,  it  would  be  better,  in  such  a  case,  to  cut 
off  a  portion  of  the  projefiing  bone,  Avhich  would  facilitate  its 
reduction,  and  prevent  an  excessive  laceration  of  the  parts.  A 
young  man  having  the  thigh  fradtured,.  with  a  p-oje£Uon  of  two 
inches  of  the  superior  fragjnent  stripped  of  its  periosteum,  was 
well  for  two  days  after  the  forced  reduction  of  this  portion,  with- 
out having  any  part  of  it  cut  off;  but  orx  the  third  day  the  limb 
became  violently  inflamed,  the  tension  and  tumefadtion  extreme, 
mortification  quickly  followed,  gained  rapidly  on  the  trunk,  and 
put  an  end  to  the  patient's  existence.  When  the  fradture  has 
been  reduced,  as  has  been  diredted,  without  too  violent  exer- 
tions, the  Avound  is  generally  treated  as  tv  simple  division  of  the 
integuments.  Copious  and  repeated  blood-letting  obviates  the 
inflammatory  symptoms  so  much  to  be  apprehended. 

When  the  wound  is  produced  by  tlie  same  cause  as  the  fradture,- 
such,  for  instance  as  the  wheel  of  a  very  heavy  carriage,  which 
causes  much  contusion,  the  nature  and  method  of  the  treatment 
must  vary  according  to  th«  circumstances  of  the  case.  If  the 
lesion  be  excessive,  the  soft  parts  torn,  enormously  contused,, 
and  almost  totally  disorganized,  the  able  and  experienced  prac- 
titioner sees  at  the  first  glance  if  the  member  be  inevitably  lost, 
or  if  mortification  be  certain:  in  which  case  he  resolves  instantly 
on  amputating,  and  prevents  by  this  conduct,  the  mischief  whicb 


OF  THE  TREATMENT  OF  FRACTURES.       35 

Triight  ensue  from  the  gangrene,  the  extent  of  which  might  prove 
fatal.  It  is  true,  that  in  many  cases  in  which  the  loss  of  the 
member  was  deemed  inevitable,  patients  have  preserved  it  by 
their  own  obstinacy.  We  ought  not  however,  on  that  account, 
to  follow  the  example  of  Van  Swieten,  who  drawing  a  general 
rule  from  a  single  fa£l,  establishes  it  as  a  maxim,  that  amputation 
should  never  be  immediately  performed  after  a  fracture.  In  sup- 
port of  this  doftrine,  he  cites  a  case  of  comminutive  fra<5ture,  in 
which  amputation  was  decided  on,  but  the  patient  was  deterred, 
or  would  not  submit  to  it.  La  Motte  treated  the  patient  as  in  less 
extraordinary  cases:  he  extracted  several  splinters,  opened  some 
abscesses,  and  succeeded  finally  in  efFefting  a  recovery,  withorit 
the  loss  of  the  limb;  but  Dot,  however,  without  having  experi- 
enced a  great  number  of  disagreeable  occurrences,  of  which  this 
surgeon  has  given  the  particulars.  It  is  impossible  to  establish 
any  general  rule  for  cases  of  this  kind.  The  surgeon  must  be 
directed  by  his  own  talents  and  sagacity  in  each  particular  case. 

In  most  cases,  if  the  injury  be  not  very  great,  the  fra6lur« 
may  be  set,  and  the  splinters,  which  are  entirely  separated  from 
Xhe  bone  and  from  the  soft  parts,  may  be  extra^d;  the  wound 
is  then  gently  dressed,  th«  bandage  of  Scultet  is  applied,  and  the 
splints  are  but  very  slightly  braced.  The  patient  is  restricted  to 
the  severest  regimen,  and  copiously  bled:  a  degree  of  inflamma- 
tion equal  to  the  extent  of  the  evil  is  to  be  eKpe(n:ed.  If,  on  the 
third  or  fourth  day,  the  tension  become  extreme,  the  part  cold 
and  livid,  with  vesicles  arising  on  it,  gangrene  is  certain.  It  is 
then  necessary  to  wait  until  the  progress  of  the  gangrene  is  ar- 
rested, which,  however,  may  be  anticipated  by  the  antiphlogistic 
regimen,  and  by  making  incisions  to  favour  the  separation.  As 
soon  as  the  mortification  is  stopped,  and  a  red  inflamed  circle 
marks  the  boundary  between  the  sound  parts  and  those  mortified, 
it  is  necessary  to  ampmat^;  for  if  the  putrid  sanies  be  absorbed 
into  the  system,  it  vyill  produce  slow  fever  and  death. 

If  the  inflammatory  swelling  terminate  by  suppuration,  as 
most  generally  happens,  it  is  apt  to  be  very  abundant.  When 
suppuration  has  commenced,  the  emollient  poultices  are  discon- 
tinued. The  dressings  are  repeated  as  often  as  may  be  necessary, 
to  prevent  the  pus  from  retarding  the  consolidation  by  stagnating 
on  the  surfaces  of  the  broken  portions.  The  strength  of  the  pa- 
tient should  be  supported  by  the  most  nourishing  diet,  and  by 
tonic  medicines,  such  as  the  extra£t  of  bark,  &c. 

By  this  treatment  it  generally  happens  that  in  about  a  month 
the  suppuration  diminishes,  the  lips  of  the  wound  begin  to  close, 
^nd  the  consolidation  of  the  fracture  advances;  but  a  greater  or 


^6  OF    THE    FORMATION    OF   CALLUS, 

less  deformity  is  inevitable,  from  the  impossibility  of  bracing  suf<» 
ficiently  the  apparatus.  In  some  cases,  the  suppuration  conti- 
nues, and  the  fragments,  always  immersed  in  pus,  cannot  reunite*, 
the  pus  is  absorbed,  and  the  patient  dies  of  the  marasmus,  to 
which  diarrhoea  and  colliquative  sweats  reduce  him.  In  order 
to  prevent  this  fatal  termination,  it  is  necessary  to  amputate  as 
soon  as  it  is  perceived  that  the  suppuration  cannot  be  stopped. 
Delay  in  this  case  would  be  very  dangerous. 

It  appears,  therefore  frpm  the  principles  which  we  have  esta- 
blished, that  comminutive  fra(fture,  always  attended  with  much 
disorder  of  the  parts,  offers  three  distinft  cases  in  which  ampu- 
tation is  necessary; 

First,  When  the  disorder  and  disorganization  is  such  as  to  ren- 
der gangrene  inevitable. 

Secondly,  When  gangrene  takes  place  in  opposition  to  the  weU 
directed  use  of  antiphlogistic  remedies. 

Thirdly,  When  the  too  abundant  suppuration  prevents  the  con- 
solidation of  the  fradlure,  and  induces  debility  and  hectic  fever. 


SECTION   VI. 

Of  the  Formation  of  Callus. 

All  that  art  can  do  in  any  fracture,  is  to  maintain  the  frag- 
ments in  contact;  their  reunion  and  identification  is  the  work  of 
nature  alone:  The  different  opinions  on  the  mode  in  which  this 
is  effected,  are  as  follow: 

The  ancients  attributed  it  to  the  effusion  of  what  they  called  the 
osseous  juice,  a  fluid  capable  of  growing  hard,  and  contrafting  strong 
adhesions  with  each  of  the  fragments,  by  which  means  it  was  suppo- 
sed to  join  them  together,  as  two  pieces  of  wood  are  united  by  glue. 
The  moderns  who  have  adopted  this  opinion  of  the  ancients, 
have  said  that  this  ossifiable  humour  was  furnished  by  the  vessels 
of  the  bone  and  surrounding  parts,  these  vessels  being  developed 
by  the  inflammatory  state.*  An  English  surgeonf  has  compared 
this  secretion  to  that  of  pus  in  the  inflammation  of  soft  parts. 
But  in  allowing  the  existence  of  this  osseous  juice  or  humour, 
■which,  by  the  bye,  is  mere  supposition  (for  the  ancients  did  not 
understand  by  it  either  the  gluten  extradied  from  bones  by  mean? 

*  See  the  Memoirs  of  Haller  and  Rordenave,  coUedled  by  Faiijeroux. 
■)•  Essays  on  Fraftures  and  Luxations,   by  John  Aitlcin.     London,   1790. 


OF    THE    FORMATION    OF    CALLUS.  37 

of  ebullition  in  Papin's  digester,  nor  the  phosphate  of  lime,  which 
fills  the  cells  formed  by  this  gelatinous  matter;)  yet  would  it  re- 
main to  be  proved  how  the  thickening  or  concretion  of  this  fluid 
could  constitute  solid  organized  matter.  By  being  effused  be- 
tween the  fragments,  this  inorganized  fluid  should  naturally  in- 
tercept or  dam  up  the  medullary  canal;  but  that  does  not  take 
place,  as  any  one  may  be  convinced,  by  splitting  a  bone  which 
had  been  fra£lured  and  re-consolidated.  Finally,  this  osseous  hu- 
mour should  naturally,  by  its  effusion,  create  tumours  of  greater 
or  less  magnitude  in  the  neighbourhood  of  the  fradlure. 

And,  in  fadt,  the  deformity  which  attends  a  great  number  of 
fra<flures  treated  without  method,  has  been  attributed  to  the  de- 
fedlive  or  superabundant  efiiision  of  this  matter.  Thus,  say  the 
advocates  of  this  opinion,  the  fraflure  of  the  clavicle  is  always 
attended  with  more  or  less  deformity,  because  the  particular  po- 
sition of  that  bone  does  not  admit  the  application  of  a  bandage, 
which,  as  in  other  cases,  might  prevent  a  redundant  effusion  of 
the  osseous  juice.  The  opinion  of  Duverney  vvas  different;  he 
thought  that  the  irregular  formation  of  the  callus  was  owing  not 
t'j  any  want  or  defeat  of  bandage,  but  to  the  bone's  being  strip- 
ped of  its  .periosteum,  and  wanting,  therefore,  the  means  of  gi- 
ving to  the  callus  its  just  conformation.  But  at  present  it  is  known 
beyond  all  doubt,  that  this  irregularity  of  form  is  to  be  ascribed 
to  the  ill  setting  of  the  fradlurc. 

When  the  phenomena  of  the  production  of  callus  were  ob- 
served with  more  care,  a  more  natural  explanation  of  this  opera- 
tion was  attempted. 

Duhamd  attributed  it  to  the  periosteum,  which  he  considered 
also  as  the  organ  of  ossification.  When  a  bone  is  fractured  (says 
that  great  naturalist),  the  periosteum  of  the  two  fragments  unites 
first;  afterwards  this  membrane  swells,  and  forms  a  kind  of 
hoop  around  the  frafture.  The  periosteum  thus  tumefied,  im- 
bibes the  humours,  softens,  and  becomes  a  kind  of  jelly,  which 
passes  quickly  to  the  state  of  cartilage.  Vessels  are  formed  in 
this  cartilaginous  substance;  and  nuclei  of  bone  originate  in  se- 
veral points,  and  gradually  unite;  and  when  the  part  of  the  pe- 
riosteum adjoining  the  fracture  is  thus  united,  it  has  the  appear- 
ance of  a  ring,  which  comprehends  each  of  the  fragments,  and 
keeps  them  united.  It  was  immediately  objc<n:ed  to  Duhamel, 
that  in  splitting  a  bone  lengthwise,  both  fragments  were  found 
united,  and  not  in  simple  contact,  like  two  pieces  of  wood  held 
together  by  a  ring,  agreeably  to  his  theory.  In  order  to  answer 
this  objedlion,  he  supposes  that  the  periosteum  extends  itself 
from  the  circumference  to  the  centre  of  the  bone,  and  that  this 


3?  OF    THE    FORMATION    OT    CALLUS. 

elongated  part  of  it  underwent  a  process  similar  to  that  of  the 
parts  contiguous  to  the  fraclure,  and  thus  identified  the  two 
pieces. 

The  intimate  adhesion  of  the  periosteum  to  the  bone,  and  its 
inextensibility,  caused  some  doubts  on  this  elongation}  besides, 
did  it  really  take  place,  the  medullary  canal  would  in  consequence 
be  obstructed.  This  theory  has,  for  these  reasons,  been  almost 
universally  abandoned,  and  has  at  present  but  few  partizans. 

When  there  happens  a  solution  of  continuity  of  the  soft  parts 
of  our  bodies,  if  the  lips  of  the  wound  be  not  brought  into  im- 
mediate contadt,  the  vessels  became  turgi<l,  the  vascular  tissue 
extends  forwards,  and  gives  rise  to  those  small  red  conical  tu- 
mours known  by  the  name  of  granulations.  This  augmentation 
in  the  calibre  of  the  vessels,  and  a  certain  degree  of  inflamma- 
tion in  the  granulations  which  arise  from  them,  are  means  which 
nature  employs  to  effect  the  reunion  of  divided  parts.  But  it  is 
not  knoAvn,  whether  or  not,  in  this  case,  the  fibres  of  one  side 
become  continuations  of  those  of  the  other;  if  the  vessels  iden- 
tify in  like  manner  by  anastomosing;  or  if  an  humour  of  a  cer- 
tain nature  be  efl:'used  between  the  divided  parts,  which  it  agglu- 
tinates together.  The  only  thing  certainly  known  on  this  subject 
is,  that  the  cicatrix  is  organized,  as  has  been  proved  by  incontest- 
able experiments. 

There  is  a  stri£l:  analogy  between  what  takes  place  in  the  soluf 
tion  of  contiuuity  of  soft  and  osseous  parts.  The  irritation  cau- 
sed by  the  fradlure  produces  the  extension  and  turgescence  of 
the  vessels  of  the  periosteum,  of  those  of  the  bone  itself,  and  of 
those  of  the  medullary  membrane ;  and  then  the  only  condition 
necessary  to  consolidation  is  that  the  fradlured  surfaces  be  pla- 
ced in  just  contact.  But  this  operation  of  nature,  by  which  an 
organized  substance  is  produced,  is  slower  in  bones  than  in  soft 
parts,  which  are  furnished  with  numerous  vessels,  and  in  which 
the  vital  properties  are  not  impeded,  as  in  the  bones,  by  the  de- 
position of  a  saline  inorganized  matter.  In  examining  a  hone  ha- 
ving a  consolidated  fraiSture,  the  place  of  the  consolidation  is 
marked  merely  by  a  line;  and  if  the  bone  be  split,  the  medulla- 
ry canal  is  found  narrowed  at  that  part,  and  in  some  cases  totally 
obstructed. 

The  production  of  granulations  on  the  membrane  which  lines 
the  bone,  accounts  for  this  narrowing  or  obstruction  of  the  me- 
dullary canal,  one  or  other  of  which  takes  place,  according  to 
the  greater  or  less  activity  of  the  vessels  of  that  part.  This  the- 
ory, suggested  by  the  striking  analogy  between  the  fleshy  and 
<j.ss<ious  parts,  supported  by  observation  of  the  phenomena  of  the 


OT   THE    FORMATION    OF    CALLUJ.  J9 

generation  of  callus  in  aniaials,  has  this  further  advantage  over 
all  the  others,  that  it  stands  uncontroverted  by  any  h€t:  on  the 
contrary,  it  is  confirmed  by  all  the  fadts  hitherto  observed.  Thus 
it  offers  a  very  natural  and  easy  explanation  of  the  difference  of 
time  required  for  the  formation  of  callus  in  youth  and  old  age, 
by  the  different  proportions  of  the  phosphate  of  lime  which  the 
bones  contain  at  these  periods. 

The  generation  of  callus  is  then  an  operation  perfectly  analo- 
gous to  the  cicatrization  of  wounded  soft  parts:  its  being  more 
tardy  is  owing  to  the  difference  in  the  activity  of  the  vital  prin- 
ciple in  these,  and  in  bony  parts.  During  a  few  days  immedi- 
ately subsequent  to  a  fracture,  the  inflammation  exists  only  in  the 
neighbouring  soft  parts,  and  the  bone  seems  perfedtly  inert;  but 
its  texture  is  soon  after  perceived  to  soften  in  that  part,  and  the 
fractured  surfaces  become  covered  with  granulations  produced  by 
the  enlargement  of  the  blood-vessels.  This  growth  takes  place 
without  any  secretion  of  pus,  and  the  consolidation  is  effedled  by 
a  process  as  little  understood  as  that  of  cicatrization.  Instead  of 
pus,  the  enlarged  vessels  secrete  and  deposit  a  calcareous  phos- 
phate, which  gives  a  solidity  equal  to  that  of  the  rest  of  the  bone. 

But  leaving  to  physiologists  the  task  of  explaining  the  forma- 
tion of  callus,  let  us  consider  what  more  particularly  interests  us, 
that  is,  the  means  of  accelerating,  retarding,  or  totally  prevent- 
ing it.  These  means  or  causes  are  either  general  or  local:  we 
shall  proceed  to  consider  both  the  one  and  the  other  in  detail. 

The  callus  is  formed,  cateris  paribus,  with  more  promptitude 
and  facility  in  infancy  and  youth  than  in  the  adult  or  irr  old  age. 
The  younger  the  individual,  the  greater  the  proportion  of  the 
gelatinous  to  the  calcareous  part  of  the  bones,  and  the  more  ra- 
pid on  that  account  is  the  organization. 

When  the  individual  is  extremely  old,  the  vital  principle  be- 
comes extin<ft,  as  it  were,  by  the  accumulation  of  calcareous  phos- 
phate, the  enlargement  of  the  vessels  cannot  take  place,  and  con- 
sequently the  consolidation,  particularly  if  to  old  age  be  joined  a 
vitiated  state  of  the  fluids,  such  as  the  scurvy,  cancer,  Sec.  can- 
not be  effe<Sted :  these  diseases  alone  suflice  in  many  cases  to  pro- 
duce the  same  effe<St.  A  strong  robust  man  of  the  sanguine  tem- 
perament, recovers  much  more  rapidly  from  a  fr-i<^ure  than  a 
weak  person,  or  one  aftefted  with  a  cachexy.  The  difference  of 
sex  causes  no  difference  in  the  generation  of  callus.  At  the  pe- 
riod, however,  of  the  cessation  of  the  menses  in  our  climate, 
that  is,  from  the  forty-fifth  to  the  fiftieth  year,  its  generation  is 
slower,  and  the  cure  of  fractures  of  women  of  that  age  is  subject 
to  the  same  irregulairities  as  their  other  diseases. 


40  OF    THE    FORMA'^IO^f    OF    CALLUS. 

The  state  of  pregnancy  does  not  perceptibly  retard  the  generd- 
tion  of  callus,  though  Fabrice  de  Hilden  wishes  to  form  a  conclu- 
sion to  the  contrary  from  the  observation  of  a  few  fa6ls. 

However  favourable  the  general  disposition  may  be  to  the  quick 
consolidation  of  a  frafture,  different  local  circumstances  may  re- 
tard it.  If  one  of  the  fractured  portions  does  not  receive  a  suf- 
ficient quantity  of  blood  to  nourish  it,  and  to  maintain  in  it  the 
necessary  vital  force,  the  vessels  will  not  be  enlarged,  nor,  of  con- 
sequence, the  fracture  consolidated.  An  instance  of  this  is  seen 
in  fraftures  of  the  neck  of  the  femur,  in  which  the  head  of  that 
bone  is  completely  separated  from  its  body,  and  the  ligament 
which  performed  the  funftions  of  periosteum,  and  which  envelo- 
ped the  neck,  is  torn;  so  that  the  only  vessels  that  enter  the  part 
of  the  bone  thus  detached,  are  those  that  pass  to  it  by  the  round 
ligament;  which  cannot  in  old  age,  when  these  vessels  are  nearly 
obliterated,  furnish  a  sufficient  quantity  of  blood  for  the  genera- 
tion of  callus.  It  is  necessary,  then,  that  both  fractured  portions 
be  endued  with  a  certain  vital  energy,  without  which  it  would  be 
as  useless  to  attempt  their  union,  as  that  of  a  gun-shot  wound  be- 
fore the  parts  disorganized  by  the  violent  contusion,  be  separated 
from  the  sound  parts  by  suppuration. 

Another  local  condition  favourable  to  the  formation  of  callus 
is,  that  the  surfaces  of  the  fractured  portions  be  brought  precise- 
ly into  contact.  Let  us  suppose,  for  example,  a  transverse  frac- 
ture of  the  femur,  and  that  the  fragments,  after  sliding  one  upon 
the  other,  have  fallen  into  the  derangement  in  the  length  of  the 
bone,  the  fraflured  portions  cannot,  in  this  case,  touch  one  ano- 
ther without  the  periosteum  intervening.  Inflammation  will  be 
extremely  slow;  and  even  at  the  end  of  two  months  the  progress 
in  the  formation  of  callus  will  be  scarcely  perceptible.  To  effeft, 
in  this  case,  a  complete  cure,  even  with  a  shortening  of  the  mem- 
ber, will  be  extremely  difficult.  It  is  therefore  absolutely  neces- 
sary to  maintain  the  fradlured  portions  in  the  position  in  which 
they  have  been  set,  as  already  prescribed. 

The  perfeft  immobility  of  the  fradlured  portions  is  not  less  es- 
sential to  their  union,  than  their  proper  contact  and  vitality.  Ir 
the  fragments  were  moved  every  day,  no  progress  towards  a  union 
could  be  made;  or  were  there  fleshy  granulations  already  formed, 
they  would  be  quickly  obliterated  by  the  friction,  and  the  surfa- 
ces would  become  smooth  and  polished.  The  periosteum  and 
cellular  texture,  distended  and  thickened,  would  form  a  kind  of 
-orbicular  ligament  round  the  ends  of  the  fractured  portions,  and 
an  unnatural  articulation  would  be  formed,  which  would  render 
the  member  absolutely  useless. 


OF    THE    FORMATION    OF    CALLUS.  41 

When  the  usual  period  of  consolidation  Is  past,  the  apparatus 
ought  to  be  taken  o£F,  and  the  limb  examined,  to  see  if  the  frac- 
tured portions  have  continued  in  the  situation  in  which  they  were 
placed,  and  if  the  whole  limb  constitute  but  one  piece.  The 
time  necessary  for  reunion  depends  on  several  circumstances,  of 
which  the  principal  are,  the  age  of  the  patient,  and  the  kind  of 
bone  fractured.  In  general,  fractures  of  the  bones  of  the  supe- 
rior extremities  are  consolidated  in  a  shorter  time  than  those  of 
the  inferior.  Thus  we  frequently  see  a  fra£ture  of  the  clavicle 
in  adults  consolidated  in  thirty  days,  and  that  of  the  radius  and 
cubitus  In  nearly  the  same  interval;  that  of  the  humerus  in  from 
about  thirty-five  to  forty  days;  whereas  those  of  the  leg  and  thigh 
require  generally  from  forty  to  fifty  days.  A  vulgar  prejudice 
exists  on  this  subjedl:  among  the  lower  order  of  persons,  who  are 
those  usually  brought  into  hospitals:  they  think  that  every  frac- 
ture ought  to  be  consolidated  in  forty  days  exactly.  But  it  is  im- 
possible to  predldt  what  time  may  be  necessary  for  this  purpose. 
In  an  infant,  consolidation  will  take  place  six  or  eight  days  soon- 
er than  in  an  adult;  and  in  an  old  man  eight  or  ten  days  later. 

If,  on  raising  the  apparatus,  the  limb  be  swelled,  or  a  tumour 
be  observed  In  the  situation  of  the  fradlure,  in  consequence  of 
the  ends  of  the  fractured  portions  having  passed  one  another; 
and  if,  at  the  same  time,  the  member,  more  or  less  shortened, 
be  moveable  in  that  part,  it  will  be  evident  that  the  fradlure  Is 
not  consolidated,  and  that  the  apparatus  has  nut  had  its  due  ef- 
fect, whether  from  being  badly  applied,  or  not  sufiiciently  exa- 
mined from  time  to  time. 

If,  instead  of  this  sweUing,  the  pieces  be  found  moveable  one 
on  the  other,  and  separated  by  a  small  interval,  and  the  member 
has  not  diminished  In  length,  the  want  of  consolidation  proceeds, 
in  this  case,  either  from  the  patient's  advanced  age,  a  vicious 
state  of  the  fluids  and  solids,  or  from  some  imprudent  motions 
of  the  limb  during  the  treatment.  In  this  latter  case,  if  the 
fracture  has  already  been  of  some  months  standing,  the  contigu- 
ous extremities  of  the  fragments  are  worn  into  a  rounded  form 
by  the  fridion,  and  surrounded  by  a  species  of  ligament  formed 
of  condensed  cellular  membrane,  so  that  an  unnatural  articula- 
tion Is  formed  at  this  place. 

Finally,  It  is  possible,  that  on  taking  off  the  apparatus,  the 
frafture  may  be  found  not  to  have  consolidated,  but  with  a 
shortening  and  deformity  of  the  limb.  In  this  case  it  will  be  re- 
quisite to  adopt  the  following  proceedings. 

If  the  ends  of  the  fractured  portions  pass  one  another,  or  if 
the  fractured  surfaces  are  partially  in  contadt,  or  totally  separated, 
6 


42  OF    THE    FaKMATiON    Of    CALLUS, 

it  will  be  necessary  to  reset  the  fra£ture,  and  to  employ  continii*-' 
ed  extension,  if  the  ordinary  means  be  insufficient  for  maintain- 
ing the  fragments  in  their  just  relative  situation.  The  duration 
of  this  second  treatment  is  at  least  as  long  as  that  of  the  first; 
for  if  the  natural  period  of  consolidation  b6  once  past,  the  frac- 
tured surfaces  are  no  longer  equally  disposed  to  unite. 

If  the  fractured  portions  continue  very  moveable  one  on  the* 
other,  notwithstanding  the  just  position  has  been  preserved,  and; 
if  the  cause  of  this  be  the  advanced  age  of  the  patient,  the  same 
apparatus  should  be  reapplied,  and  the  vigour  of  the  patient  in- 
creased by  the  v;ell  directed  use  of  wine  and  nourishing  diet. 
By  persevering  in  these  means  a  cure  is  at  length  effefted  in  the 
space  of  five  or  six  months.  But  if  some  constitutional  disease, 
such  as  cancer,  scurvy,  &c.  be  suspe£led  of  being  the  cause  of 
non-consolidation,  these  diseases  must  be  combatted  by  appro- 
priate remedies,  the  mechanical  means  persevered  in,  and  every 
kind  of  motion  of  the  limb  abstained  from. 

But  whether  the  fradlured  portions  have  passed  one  another, 
or  whether  an  articulation  has  been  formed  between  the  fra<ftured 
surfaces,  if  the  fra<fture  has  been  already  of  several  months  du- 
ration, the  aftion  of  the  fradlured  surfaces  ought  to  be  revived 
by  rubbing  them  forcibly  one  against  the  other,  in  order  to  ex- 
cite the  degree  of  inflammation  necessary  for  the  generation  of 
callus.  The  fractured  ends  of  the  bones  having  by  these  means 
acquired  a  disposition  favourable  to  their  agglutination,  the  ap- 
paratus should  be  reapplied,  the  extension  continued,  if  neces- 
sary, and  the  treatment  prolonged  until  the  cure  be  complete. 

If,  notwithstanding  these  means,  the  pieces  do  not  unite, 
there  remains  another  and  last  resource,  the  cutting  off  of  their 
extremities.  This  operation  is  painful,  terrifying,  and  of  dubious 
event;  its  success  has,  however,  been  frequent  enough  to  war- 
rant the  trial.  It  would  be  impracticable  in  fradlures  of  the  leg 
and  fore-arm,  on  account  of  the  difficulty  of  separating  from  the' 
integuments  the  two  bones  of  which  each  of  these  parts  is  form- 
ed, and  on  account  of  the  numerous  nerves  and  arteries  which 
would  be  in  danger  of  being  wounded  by  the  large  incisions  ne- 
cessary for  this  operation.  It  is  therefore  pra61;ioable  only  in  the 
femur  and  humerus,  especially  the  latter. 

This  operation  is  performed  by  making  a  longitudinal  incision 
ever  the  fradture,  on  that  side  of  the  limb  where  the  bone  is 
most  prominent  and  least  covered;  the  nerves  and  vessels  are  ta 
be  avoided  with  the  utmost  care;  each  end  of  the  fractured  por- 
tions is  nicely  laid  bare,  and  made  to  project  beyond  the  soft 
parts,  which  may  be  protected  by  compresses,  or  by  a  thin  plate 


OF    THE    FORMATION    OF    CALLUS.  43 

of  lead  or  pasteboard,  from  the  aftion  of  the  saw  with  which  a 
sufficient  quantity  of  each  fragment  is  to  be  taken  ofF.  This  part 
«f  the  operation  being  performed,  the  extremities  of  the  fradlured 
.portions  are  restored  to  the  position  which  they  ought  to  have, 
and  tlie  woand  dressed  with  soft  hnt,  in  short,  the  subsequent 
treatment  is  the  same  as  tliat  already  prescribed  in  the  case  of 
compound  frafture;  that  is,  Scultet's  bandage  is  to  be  appUed 
moderately  tight,  as  well  as  the  splints  and  other  parts  of  the 
apparatus;  for  beyond  all  doubt  a  violent  inflanunation  and  copi- 
ous suppuration  will  succeed.  An  abundant  formation  of  puru- 
Jent  matter  is  disadvantageous,  on  account  of  the  pus  stagnating 
in  the  bottom  of  the  wound,  lubricating  the  fra<ftured  surfaces, 
and  preventing  their  agglutination. 

Citizen  Boyer  has  performed  this  operation  but  once;  and  al- 
though he  was  not  successful,  I  think  it  my  duty  to  mention  the 
case. 

A  man,  aged  thirty-six,  had  his  right  arm  fra£lured,  and  no- 
thing was  done  to  adjust  the  fraftured  bone.  The  solution  of  con- 
tinuity took  place  above  the  middle  part  of  the  humerus:  this  arm 
had  been  for  so  long  a  time  useless  to  the  patient,  that  he  was 
determined  to  undergo  any  tri^l  for  efFefting  a  cure,  but  would 
not  listen  to  any  proposal  of  amputation.  This  operation  was 
then  resolved  on:  an  i:icision  was  made  over  the  fracture  on  the 
external  sidte  of  the  arm,  a  little  above  the  place  where  the  radial 
nerve  winds  on  the  humerus,  for  the  purpose  of  saving  this 
nerve,  and  thus  preserving  from  paralysis  the  posterior  muscles 
of  the  fore  arm:  this  incision  being  made,  he  exposed  the  end  of 
the  inferior  fragment,  and  caused  it  to  project  by  raising  the  el- 
bow and  pushing  it  inward. 

The  soft  parts  were  prote£ted  by  means  of  a  plate  of  wood, 
and  the  conical  or  rounded  part  of  the  ends  of  the  bone  was  then 
sawed  oflF.  The  part  of  the  operation  for  the  superior  portions 
was  more  difficult;  for  the  conical  part  was  longer  and  the  point 
sharper:  one  of  the  collateral  arteries  was  opened,  on  which  a 
ligature  was  applied.  The  end  being  sawed  off,  as  in  the  former 
case,  and  with  the  same  precautions,  and  both  fractured  portions 
being  restored  to  their  natural  direction,  it  was  found  that  they 
were  separated  one  from  the  other  by  an  interval  of  two  inches 
and  an  half.  In  brder  to  bring  them  into  contact,  the  elbow  was 
raised  by  means  of  two  casts  of  a  bandage,  drawn  from  the  fore- 
arm bent  to  the  shoulder  of  the  opposite  side.  For  the  two  first 
days  immediately  after  the  operation,  no  bad  symptom  took 
place.  The  inflammatory  swelling  and  tension,  as  well  as  the 
fever,  were  such  as  might  be  expected  from  the  extent  of  the 


44  OF    THE    FORMATION    OF    CALLUS. 

wound.  But  on  the  third  day  the  fever  became  more  violent 5 
a  redness,  and  quickly  after  an  erysipelas,  appeared  on  the  arm 
of  the  opposite  side;  the  inflammation  extended  to  the  shoulder, 
and  afterwards  to  the  fractured  arm.  The  tension  was  extreme; 
instead  of  pus  there  flowed  from  the  wound  a  bloody  sanies^ 
gangrene  came  on,  and  the  patient  died  on  the  sixth  day. 

The  cure  obtained  by  this  operation  is  necessarily  attended 
with  a  shortening  of  the  member;  but  this  inconvenience  is  but 
slight  with  respe6l  to  the  arm:  in  the  thigh  it  is  evident  that 
more  or  less  lameness  is  necessarily  the  consequence  of  it. 

It  cannot  be  denied  but  that  this  operation  is  one  of  the  most 
difiicult  in  surgery,  but  it  ought  not  to  be  renounced  for  that 
reason,  when  any  hope  may  be  had  of  recovering  by  it  the  usie 
of  a  disabled  member,  and  when  the  patient  wishes  at  all  risks 
to  make  the  experiment.  But  should  the  patient  prefer  ampu- 
tation to  this  cruel  and  uncertain  chance,  that  operation  ought  t6. 
be  recurred  to,  when  all  the  other  resources  of  our  art  have  been 
tried  in  vain. 

The  progress  of  the  callus  to  perfect  consolidation  is,  analo- 
gously to  that  of  the  osseous  system  in  general,  slow  and  gradual. 
The  patient  is  not,  therefore,  to  be  allowed  the  free  use  of  a 
fra^lured  limb  immediately  after  the  reunion  of  the  fracture.  In 
fraflures  of  the  inferior  extremities,  crutches  ought  to  be  used 
for  some  time,  and  the  limb  which  had  been  fractured  charged 
with  its  share  of  the  weight  of  the  body,  but  by  little  and  little. 
From  not  paying  sufficient  attention  to  this  circumstance,  the 
callus  has  been  sometimes  so  much  pressed,  as  that  the  limb  was 
shortened,  and  consequently  lameness  induced.  Besides,  the 
slightest  false  step  might  cause  a  relapse  of  the  fracture;  for,  not- 
withstanding what  certain  authors  have  said  to  the  contrary,  the 
consolidated  part  of  a  fractured  bone  is  never  stronger  than  the 
other  parts,  nor  even  equally  strong,  until  after  a  considerable 
lapse  of  time. 

To  procure  the  reunion  of  the  fragments  without  any  shortening 
of  the  limb,  is  not  the  sole  objedt  to  be  attended  to  in  the  treat- 
ment of  a  fradture.  During  the  time  that  the  member  is  neces- 
sarily motionless,  the  muscles  lose  the  habit  of  motion,  and  grow 
rigid,  and  a  false  anchylosis  frequently  follows-.  This  conse- 
quence is  particularly  to  be  apprehended  in  fradtures  which  take 
place  near  the  articulations  (as  has  been  already  mentioned),  in 
those,  for  instance,  of  the  patella,  of  the  inferior  extremity  of 
the  femur,  of  the  olecranon,  or  of  the  condyles  of  the  humerus. 
It  most  frequently  takes  place  in  the  articulations  of  the  knee,  el- 
bow and  instep.     It  may  be  prevented  by  gently  moving  the  limb 


OF  THE    FORMATION    OF    CALLUS."  45 

from  time  to  time,  as  soon  as  the  consolidation  is  so  far  advanced 
as  that  its  progress  cannot  be  retarded  by  these  motions.  Finally,  a 
false  anchylosis  may  be  removed  by  general  bathing,  by  the  use 
of  the  shower-bath,  by  resolvent  plasters,  and  by  continued  and 
gentle  efforts,  as  shall  be  more  fully  detailed  in  treating  of  that 
iaffeftion. 

As  fraiftures  of  the  skull  are  more  important  by  the  necessarily 
attendant  affection  of  the  brain  than  by  the  simple  consideration 
of  the  fracture,  we  think  it  most  methodical  to  refer  them  to 
wounds  of  the  head.  The  same  may  be  said  of  the  greater  part 
of  the  fraftures  of  the  bones  of  the  upper  jaw,  the  parts  of  which 
being  strongly  united  together,  and  to  the  bones  of  the  skull, 
render  them  susceptible  only  of  comminutive  fracture,  when  the 
fra^lured  part  is  that  on  which  the  cause  has  immediately  afted. 

Let  us  suppose  that  the  wheel  of  a  carriage  rolls  over  a  per- 
son's head  (of  which  the  examples  are  but  too  frequent),  and  that 
the  zygomatic  arch  is  thereby  fractured ;  in  such  a  case  the  sur- 
geon's duty  would  be  merely  to  bleed  the  patient,  and  use  other 
means  to  combat  the  inflammatory  symptoms.  It  would  not  be 
prudent  to  make  an  incision  into  the  depression  of  the  temple,  in 
order  to  raise  the  zygomatic  arch,  at  the  risk  of  opening  the  tem- 
poral superficial  artery,  and  of  causing  much  pain  by  the  lacera- 
tion of  the  nerves,  except  in  the  case  that  the  fradtured  bone 
crushed  into  the  crotaphyte  muscle,  should  excite  great  pain  and 
other  bad  consequences. 

If  in  a  fra(Slure  of  the  superior  maxillary  bones,  there  should 
be  detached  from  the  body  of  one  of  these  bones,  a  part  of  the 
alveolar  process  with  one  or  more  teeth,  as  in  the  third  case  of  Le- 
dran's  Surgical  Observations,  it  would  be  necessary  to  follow  the 
example  of  this  surgeon;  viz.  to  fasten  silk  threads  to  the  teeth 
of  the  broken  portion,  which  adheres  still  by  the  gum,  and  by 
the  internal  membrane  of  the  mouth;  and  then  to  attach  these 
threads  to  the  teeth  of  the  adjacent  sound  part,  the  fragment  be- 
ing first  placed  in  its  natural  situation.  Dentists  frequently  em- 
ploy this  mean  for  the  purpose  of  fastening  artificial  teeth;  and 
its  use  has  been  advised  in  cases  of  fradlure  of  the  lower  jaw. 
We  shall  give  the  details  of  the  fractures  of  this  last-mentioned 
bone,  after  having  first  treated  of  those  of  the  bones  of  the  nose; 
these  being  in  this  respeft  the  only  bones  of  the  face  which  me- 
rit particular  consideration. 


4^ 


CHAPTER  11. 


OF  THE  FRACTURES  OF  THE  BONES  OF  THE  NOSE. 

THESE  symmetrical  bones,  with  the  ascending  processes  of 
the  maxillary  bones  by  which  they  are  supported,  form  a 
kind  of  arch.  As  they  projeft  in  the  middle  of  the  face,  and  are 
but  slightly  covered  by  soft  parts,  they  are  much  exposed  to  dif- 
ferent kinds  of  frafture  from  different  causes. 

In  all  these  cases  the  cause  of  the  fradlure  is  always  applied  to 
that  part  immediately  where  the  solution  of  continuity  takes  place, 
and  the  fradlure  may  be  oblique,  longitudinal,  or  transverse, 
without  derangement  of  the  fragments;  but  it  more  frequently 
happens  that  the  bones  are  splintered  and  crushed  into  the  cavity 
of  the  nostril;  that  the  nose  loses  its  natural  form,  and  that  the 
neighbouring  soft  parts  are  much  bruised  by  being  crushed  be- 
tween the  bones  and  the  cause  of  the  fradture,  whether  a  body 
against  which  the  nose  has  been  forcibly  struck,  or  one  which 
may  have  been  strongly  impelled  against  it. 

■  If  the  soft  parts  have  suffered  no  solution  of  continuity,  an4 
if  the  fragments  have  not  been  displaced,  the  fracture  may  not  be 
discovered,  because  the  form  of  the  nose  does  not  change.  An 
oversight  in  this  case  is  not  dangerous,  as  the  use  of  emollients  and 
resolvents  is  all  that  is  required.  If  the  fra£lure  be  comminutive, 
not  only  the  inflammatory  symptoms  ought  to  be  combatted  by 
blood-letting  and  other  antiphlogistic  aaieans,  but  further,  the 
fragments  ought  to  be  replaced,  as  they  strain  and  irritate  the 
soft  parts,  already  contused,  by  their  unnatural  situation.  For 
that  purpose  the  operator  takes  a  grooved  sound,  a  female  cathe- 
ter, a  ringhandled  forceps,  or  any  such  instrument,  introduces  h 
into  the  nostrils,  and  by  using  it  as  a  lever,  pushes  the  fragments 
outward;  at  the  same  time  with  the  index  of  the  left  hand  applied 
to  the  ridge  of  the  nose,  he  prevents  them  from  being  pushed  out 
too  far,  and  from  lacerating  the  integuments.  Sometimes  the 
bones  continue  in  the  situation  in  which  they  have  been  thus 
placed;  but  it  may  happen,  that,  from  being  much  fraftured,  and 
badly  supported  by  the  soft  parts,  they  fall  again  inwards;  in 
which  case  a  canula  of  elastic  gum  should  be  directed  along  th^ 


OF  THE  FRACTURES  OF  THE  BONES  OF  THE  NOSE.   47 

inferior  surface  of  each  nostril,  which  ought  then  to  be  stuffed 
with  lint,  and  gently  thrust  in,  lest  the  pituitary  membrane  should 
be  hurt. 

In  cases  of  comminutlve  frafture,  with  depression  of  the  splin- 
ters, it  would  be  imprudent  to  wait  the  disappearance  of  the  in- 
flammatory symptoms,  before  making  an  attempt  to  raise  and  ad- 
just the  fragments;  because,  during  the  interval,  the  portions  of 
bone  might  reunite  in  an  unnatural  situation,  and  produce  de- 
formity of  the  nose. 

Frafture  of  the  nasal  bones  is  sometimes  attended  w^ith  very 
dangerous  symptoms,  whether  produced  by  a  violent  commotion 
given  to  the  head  by  the  cause  of  the  fradlure,  or  by  a  co- exist- 
ing frafture  of  the  bones  of  the  skull;  or,  as  some  authors  think, 
by  the  concussion  communicated  to  the  perpendicular  part  of  the 
ethmoidal  bone,  and  thence  to  its  cribriform  part,  which  would, 
in  that  case,  be  fractured,  on  account  of  its  great  tenuity.  The 
laceration  of  the  dura  mater  and  its  vessels,  caused  by  the  fradlure 
of  the  cribriform  lamella  of  the  ethmoidal  bone,  would  produce 
effusion,  and  thus  give  rise  to  all  the  symptoms.  It  is  certain 
that  cases  have  occurred  where  blows  on  the  root  of  the  hose  have 
produced  coma,  convulsions,  and  death;  particularly  when  the 
nasal  bones  were  not  fradlured.  How  such  an  injury  may  take 
place  may  be  easily  conceived  by  the  consideration  of  the  effedl  of 
contre-coup,  commotion,  and  other  consequences  which  may  en- 
sue, if  a  great  part  of  the  percussive  force  be  not  consumed  m 
producing  the  fradlure. 

This  etiology  is,  however,  applicable  but  to  persons  advanced  in 
age,  because  in  youth  the  perpendicular  part  of  the  ethmoidal 
bone  articulates  with  only  a  very  small  part  of  the  nasal  bones; 
the  rest  of  these  bones  being  then  supported  by  the  cartilage 
which  separates  the  nostrils,  and  with  which  that  part  of  the  eth- 
moidal bone  is  connefted.  At  this  last  mentioned  period,  the 
nasal  processes  of  the  os  frontis  are  their  principal  support,  and 
ought  therefore  to  receive  the  principal  part  of  the  concussion. 


4i 


CHAPTER  III. 


OF  THE  FRACTURES  OF  THE  LOWER  JAW. 

THE  great  mobility  of  this  bone  is  the  reason  of  its  being 
seldom  fradhired.  A  violent  blow  may  however  fra6ture  it, 
and  wound  at  the  same  time,  more  or  less,  the  neighbouring  soft 
parts.  It  may  also  be  fradlured  by  the  passage  of  the  wheel  of 
a  carriage  across  it.  An  impelled  force  which  fradtures  this  bone 
tends  first  to  increase  the  elliptic  curve  which  is  its  natural  form, 
and  that  in  proportion  as  it  a£ls  nearer  to,  or  farther  from  the 
angle  of  that  bone  •,  so  that  if  a  succession  can  be  admitted  in  the 
rupture  of  the  fibres,  the  rupture  ought  to  commence  in  those 
which  are  external.  When  on  the  contrary,  the  solution  of  con- 
tinuity is  the  effect  of  a  force  immediately  and  direftly  applied 
on  the  part  that  breaks,  there  is  no  tendency  to  increase  the  na- 
tural curve,  but  that  part  is  pushed  inward,  and  the  solution  of 
continuity  commences  on  the  inside. 

These  fra^ures  vary,  first,  as  to  the  part  of  the  bone  fractured. 
That  sometimes  takes  place  near  the  chin,  but  seldom  so  as  to  pro- 
duce the  division  of  the  symphysis  of  that  part,  though  it  be  not 
impossible.  At  other  times  the  fracture  takes  place  more  or  less 
near  the  angle  of  the  bone.  Two  fra£lures  may  occur  in  it  at  the 
same  time,  by  which  it  would  be  divided  into  three  pieces,  of 
which,  that  corresponding  to  the  chin  is  extremely  difficult  to 
manage;  because  many  of  the  muscles  which  draw  the  lower  jaw 
downwards,  are  attached  to  that  part. 

The  lower  jaw  is  subjedt  to  be  fra£tured,  not  only  near  the 
symphysis,  but  also  near  the  processes  which  terminate  its  branch- 
es; that  is,  near  the  condyles  and  the  coronoid  processes.  Of 
these  two  parts,  the  condyle  is  that  which  is  the  more  frequently 
fra£lured,  it  being  covered  merely  by  the  parotid  gland;  the  co- 
ronoid process  being,  on  the  contrary,  protedled  by  the  temporal 
muscle,  by  the  masseter  and  by  the  zygomatic  process. 

The  fra£lures  of  the  lower  jaw  may  vary  infinitely  in  their  di- 
reflions;  be  perpendicular  to  its  basis,  oblique,  or  longitudinal: 
of  this  latter,  examples  have  been  seen,  in  which  a  portion  of  the 


OF  THE  FRACTURES  OF  THE  LOWER  JAW.     49 

alveolar  part,  with  the  teeth  implanted  in  it,  was  detached  from 
the  rest  of  the  bone. 

These  fraclures  are  seldorh  simple,  particularly  if  the  frafturing 
cause  has  been  dire(n:ly  applied.  The  soft  parts'  are  always  more 
or  less  contused  or  wounded.  J.  L.  Petit  mentions  an  instance  of 
the  complete  denudation  of  the  coronold  process,  in  a  case  of 
fradlure  by  a  kick  from  a  horse. 

In  order  to  form  a  clear  idea  of  the  different  ways  in  which  the 
fra<5lured  portions  of  the  lower  jaw  may  be  deranged,  it  is  neces- 
sary to  take  a  brief  view  of  the  muscles  by  which  that  bone  is 
moved.  The  temporal  muscle  having  its  convergent  fibres  col- 
ledled  into  one  parcel,  descends  from  the  temporal  to  the  zygo- 
matic fossa,  and  embraces  with  its  inferior  angle  the  coronoid 
process  of  the  lower  jaw,  of  which  it  is  the  principal  elevator. 
The  masseter  descends  from  the  zygomatic  arch  to  the  external 
side  of  the  branch  of  the  lower  jaw.  The  pterygoideus  intcrnus 
descends  obliquely  backward  to  the  internal  side  of  the  same  an- 
gle: this  muscle  serves  not  dnly  to  raise  the  lower  jaw',  but  also 
to  move  it  a  little  forward.  This  last  motion  is  however,  especi- 
ally performed  by  the  pterygoideus  externus,  which,  passing  ob- 
liquely outward  and  backward,  embraces  the  neck,  ot*  narrowed 
part  which  supports  the  condyle. 

The  muscles  which  draw  down  the  lower  jaw,  ire  attached  to 
the  body  of  that  bone,  and  especially  to  the  process  at  the  chin. 
The  greater  part  of  these  muscles  come    from  the  os  hyoides.  • 
Those  attached  to  it  are  the  platysma  myoides,  the  digastrici,  the 
niylo-hyoidei,  the  genio-hyoidei,  and  the  genio  glossi. 

Let  us  see  in  the  next  place,  how  these  different  muscles  con- 
tribute to  produce  the  derangement  of  the  fractured  portions.  If 
the  frafture  be  near  the  symphysis,  on  Which  is  the  processus  in- 
nominatus,  that  side  to  which  this  process  belongs,  is  drawn 
downward  and  backward  by  the  submaxillary  muscles,  and  even 
by  those  which  extend  from  the  clavicle  and  sternum,  to  the  os 
hyoides,  while  the  other  fragment  is  supported  by  the  levator 
muscles-,  if  the  fradture  be  more  backward  toward  the  branches, 
the  derangement  takes  place  in  the  same  manner,  but  with  a  lit- 
tle more  difficulty.  In  the  double  fraiSlures,  the  middle  portion  is 
perpetually  drawn  downward  and  backward  by  the  muscles  which 
are  attached  to  the  process  at  the  chin,  whilst  the  two  lateral  are 
supported  by  the  levator-muscles. 

If  the  branch  be  the  part  fradtured,   any  considerable  degree 
of  derangement  is  prevented  by  the  masseter  which  is  attached 
to  each  of  the  fractured  portions.     If  the  neck  of  the  condyle  be 
7 


^O  OF    THE    FRACTURES  OF    THE    LOWER    JAW. 

the  part  fra(Stured,  the  condyle  will  be  drawn  forward  by  the 
adlion  of  the  pterygoideus  externus. 

All  these  different  derangements,  except  the  last,  take  place 
in  the  same  line  as  that  which  passes  from  the  teeth  to  the  basis 
of  the  bone.  The  fradlured  portions  are  never  deranged  so  as 
that  one  passes  on  the  other,  or  in  the  direction  of  their  length; 
for  the  action  of  none  of  the  muscles  of  the  lower  jaw  is  parallel 
to  the  axis  of  that  bone:  besides,  its  extremities  are  retained  in 
the  glenoidal  cavities  of  the  temporal  bones. 

When  a  blow  is  received  on  the  lower  jaw,  or  the  bone  is  in-  . 
jured  by  a  fall  on  that  part,  or  by  the  pressure  of  some  heavy  bo- 
dy, and  at  the  same  time  an  acute  pain  is  felt  in  the  part;  and 
when,  with  these  circumstances,  an  inequality  is  found  at  the  ba- 
sis of  that  bone  by  moving  the  fingers  along  it;  when  some  of 
the  teeth,  corresponding  to  that  inequality,  are  found  to  have 
lost  their  level,  one  being  lower  than  the  other;  and  when,  be- 
sides, by  seizing  these  apparently  deranged  parts,  one  in  each 
hand,  and  impelling  them  in  opposite  directions,  a  mobility  and 
crepitation  are  perceived,  there  can  be  no  doubt  as  to  the  exist- 
ence of  a  frafture;  although  there  be  no  denudation  of  the  bone 
by  wound,  nor  any  laceration  of  the  gums;  circumstances,  how- 
ever, which  would  render  the  fradture  still  more  evident. 

The  fradlures  of  the  branches  and  condyles  are  not  so  easily 
distinguished  as  those  of  the  body  of  the  bone.  Yet  t}xe  acute 
{lain  which  the  patient  feels  in  the  region  of  the  ear,  especially 
when  he  moves  the  jaw,  the  crepitation  produced  by  these  mo- 
tions, or  by  pressure  on  the  condyle,  are  sufficient  evidence  of 
its  existence;  if  an  inflammatory  swelling  has  not  taken  place  be- 
fore the  surgeon  has  been  called  in.  In  that  case,  the  diagnosis 
cannot  be  established,  until,  by  the  lapse  of  a  few  days,  by  bleed- 
ing, poultices,  and  regimen,  the  tumour  has  been  dissipated. 

Fra6ture  of  the  lower  jaw  is  in  general  not  very  dangerous. 
When  simple,  it  would  get  well  spontaneously;  but  there  would 
be,  it  is  true,  some  deformity,  which  it  is  the  surgeon's  duty  to 
prevent. 

Compound  fractures  of  the  lower  jaw  are  more  dangerous;  and 
if  the  nerve  which  goes  to  the  teeth,  be  torn,  which  rarely  hap- 
pens, because  the  greater  part  of  these  fradtures  take  place  between 
the  symphysis  and  the  foramen  by  which  this  nerve  comes  out 
from  the  conduit  through  which  it  runs  in  the  substance  of  the 
bone,  the  square  and  triangular  muscles  of  the  chin  are  paralysed. 
The  skin  of  that  part  and  the  internal  membrane  of  the  under 
lip  preserve  their  sensibiUty,  which  it  appears  they  owe  to  some 


I 


OF  THE  FRACTURES  OF  THE  LOWER  JAW.     ^l 

threads  of  the  portio  dura  of  the  seventh  pair;  but  the  paralysis 
of  these  muscles  does  not  prove  of  itself  that  the  jaw  is  fradtured 

In  order  to  set  afra^ure  simple  or  double  of  the  lovv^er  jaw,  it 
suffices  to  push  the  deranged  part  upward  and  a  little  forward,  and 
afterwards,  by  pressing  on  the  basis  of  the  bone,  to  bring  it  ex- 
actly on  a  level  with  the  portion  which  has  preserved  its  natural 
position;  which  may  be  done  by  bringing  all  the  teeth  of  the 
lower  jaw  into  close  contact  with  those  of  the  upper.  But  the 
facility  of  setting  this  fradlure  is  more  than  counterbalanced  by 
the  difficulty  of  maintaining  it  set.  Different  means  of  accom- 
plishing this  purpose  have  been  proposed;  but  those  alone  a£t  ef- 
ficaciously which  keep  both  jaws  together,  by  supporting  the  lovrcr 
jaw,  and  keeping  it  applied  to  the  superior  or  upper  jaw. 

All  other  means  would  be  useless,  if  the  jaw  were  not  kept  per- 
feftly  motionless.  And  this  immobility  is  extremely  difficult  to 
be  obtained,  on  account  of  the  motions  induced  by  mastication, 
deglutition,  and  speech;  but  which  ought  to  be  suspended  for  a 
time.  For  the  two  or  three  first  days  the  patient  should  be  re- 
strained to  a  very  small  quantity  of  food  and  nourished  afterwards 
with  broths,  which  may  be  given  by  introducing  a  small  spoon 
between  the  teeth  a  little  separated.  If  he  should  happen  to 
want  a  tooth,  that  will  be  a  fortunate  circumstance  on  this  occa- 
sion, because  broths  may  be  given  through  the  opening  by 
means  of  a  canula,  without  causing  the  least  motion  to  the  frac- 
tured bone.  If  the  patient  be  unmanageable,  and  insist  on  eat- 
ing or  speaking,  in  opposition  to  the  surgeon's  advice,  the  forma- 
tion of  the  callus  will  be  slow,  and  the  cure  difficult,  and  inevi- 
tably attended  with  deformity.  An  opening  might  also  be  pre- 
served by  introducing  two  pieces  of  cork,  one  on  each  side  be- 
tween the  teeth. 

It  has  been  proposed  to  tie  the  two  pieces  together  by  means  of 
a  gold  or  silver  wire,  passed  from  some  of  the  teeth  on  one  side 
of  the  fracture,  to  those  adjacent  on  the  other  side.  But  exclu- 
sively of  this  being  very  difficult,  and  even  impossible  in  persons 
who  have  the  teeth  very  close  set,  the  wire  could  only  prevent  the 
longitudinal  derangement.  But  we  have  already  shewn  that  the 
fractured  portions  have  no  tendency  to  derangement  in  that  direc- 
tion, and  consequently,  that  this  expedient  could  be  of  use  only 
in  case  of  a  part  of  the  alveolar  process  being  detached  from  the 
rest  of  the  bone. 

Some  pradlitioners  have  made  use  of  a  pasteboard  mould,  com- 
posed of  a  semicircular  piece,  excavated  for  the  purpose  of  recei- 
ving the  neck:  This  piece  is  placed  horizontally,  with  its  convex 
edge  projedting  a  little  beyond  the  basis  of  the  lower  jaw.    Ano- 


52     OF  THE  FRACTURES  OF  THE  LOWER  JAW, 

ther  piece,  of  about  an  inch  in  breadth,  is  placed  so  as  to  extend 
from  one  angle  of  the  jaw  bone  to  the  other,  having  its  under 
edge  corresponding  to  the  outer  edge  of  the  other,  and  its  upper 
edge  on  a  level  ^yith  the  under  lip.  Both  these  pieces  are  moi- 
stened with  a  resolvent  liquid,  which  renders  them  flexible  and 
more  easily  adapted  to  the  form  of  the  jaw.  On  these  pieces  are 
placed  compresses,  also  moistened  with  a  resolvent  liquid,  and  a 
chin  bandage  is  applied  over  all.  Although  the  pasteboard,  on 
being  dry,  constitutes  a  kind  of  mould,  in  which  the  lower  jaw 
is  contained,  yet  as  it  a6ls  on  the  fra<fture  only  as  it  is  afted  on  by 
the  bandages,  and  as  it  injures  by  its  hardness  the  soft  parts 
on  which  it  presses,  it  has  been  abandoned. 

If  the  fradlure  be  simple,  the  operator  will  commence  by  apr 
plying  two  bands  externally,  of  three  fingers  breadth  each:  one 
of  these  is  to  be  passed  under  the  chin,  and  fastened  on  the  top 
of  the  head  to  the  patient's  cap-,  the  other  is  to  be  applied  imme- 
diately to  the  chin  and  jaw,  and  fastened  at  the  occiput;  after 
which  the  chin  bandage  is  applied;  this  bandage  must  be  so  long 
as  that  the  two  ends  of  it  may  cross  on  the  top  of  the  head,  and 
broad  enough  to  extend  from  the  lip  to  the  middle  point  between 
the  chin  and  the  neck.  The  extremities  of  this  bandage  are  split 
to  near  the  middle  part,  in  which  a  hole  is  made  to  receive  the 
chin,  and  two  ends  are  knotted  on  the  top  of  the  head,  and  the 
other  two  on  the  occiput.  For  greater  security,  two  bandages  of 
this  construction  might  be  applied;  but  if  the  patient  be  perverse, 
and  the  fracture  double,  it  will  be  necessary  to  apply  the  double 
chevestrcy  which  is  more  easily  done  than  described. 

Fra£lure  of  the  condyles  requires  the  following  modification  of 
the  apparatus.  As  that  process  is  incessantly  drawn  forward  by 
the  ptcrygoideus  externus,  it  would  be  necessary  to  push  it  back; 
but  being  so  short,  and  situated  so  deeply  it  cannot  be  adted  on 
but  with  great  difHculty;  for  which  reason  the  lower  portion  must, 
if  possible,  be  pushed  into  contact  with  the  condyle,  which  may 
be  done  by  making  the  chevestre  aft  on  the  angle,  and  aiding  its 
adlion  by  means  of  a  thick  and  graduated  compress  placed  on  that 
angle.  It  is  almost  needless  to  remark,  that  if  both  condyles  be 
fractured,  the  double  chevestre  ought  to  be  employed ;  in  this 
case  the  parts  are  with  difHculty  kept  in  their  situation;  the  ap- 
paratus ought  therefore  to  be  often  examined,  and  reapplied  fre- 
quently. 

It  is  particularly  important  in  fractures  of  the  condyles  to  ob- 
tain a  cure  without  deformity,  because  the  motion  of  the  bone 
would  be  afTefted  by  any  deformity  that  would  remain.     If  the 


OF  THE  FRACTURES  OF  THE  LOWER  JAW,     5^ 

patient  insists  on  eating  or  speaking  during  the  treatment,  it  is 
probable  that  there  will  be  no  reunion,  that  the  condyle  will  ex- 
joliate,  and  be  cast  out  through  a  fistulous  opening.  Thus  a  cart- 
er, who  quitted  the  hospital  De  la  Charite,  after  being  three 
months  a  patient  in  it,  but  without  being  perfectly  cured  of  a 
double  fracture  of  thelower  jaw,  one  near  the  middle  part,  the 
Other  near  the  right  condyle,  returned  after  an  absence  of  seven 
or  eight  months  to  Citizen  Boyer,  who  extrafted  from  a  fistula, 
in  the  external  conduit  of  the  ear,  a  bony  mass,  which  had  evi- 
dently the  form  of  the  condyle. 

When  at  the  end  of  fifteen  or  twenty  days,  the  pieces  begin 
to  unite,  soft  food  maybe  given  to  the  patient,  instead  of  broths; 
and  according  as  the  solidity  augments,  the  consistence  of  the 
food  may  be  increased.  The  cure  will  be  complete  between  the 
thirtieth  and  thirty-fifth  day,  if  nothing  interrupts  its  natural 
progress. 

After  what  we  have  already  said  on  compound  fi*a£tures,  in 
treating  of  fractures  in  general,  it  is  unnecessary  to  repeat  here 
particularly  what  is  there  related,  and  which  may  be  so  easily 
applied  to  the  fi-a£lure  of  the  lower  jaw,  attended  with  vio- 
lent contusion,  or  a  division  of  the  soft  parts  covering  it.  It 
may  be  remembered,  however,  that  this  bone  frequently  exfoli- 
ates, when  the  frafture  is  accompanied  with  a  wound,  and  that 
the  cure  is  on  that  account  much  more  tedious. 


54 


CHAPTER  IV. 


OF  THE  FRACTURES  OF  THE  VERTEBRA. 

THE  bones  which  compose  the  spine  are  seldom  fradlured, 
because,  hke  otlier  short  bones,  they  resist  any  violence 
that  might  be  appUed  to  them,  by  the  equahty  of  their  three  di- 
mensions. If  any  great  force  be  appUed  to  the  vertebral  column, 
it  is  apter  to  lacerate  the  intervertebral  cartilages,  or  to  separate 
them  from  the  vertebrae,  than  to  fradture  these  bones:  they  may 
however,  be  fradtured  in  the  very  part  against  which  the  force 
has  been  immediately  applied.  The  spinal  processes  which  pro-, 
je6t  from  the  body  of  the  bones  is  the  part  most  liable  to  be  frac- 
tured, because  it  is  that  which  is  weakest  and  the  most  superfici- 
ally situated.  But  it  seldom  happens  that  the  fracture  is  limited 
to  a  single  vertebra-,  several  of  them  are  generally  fractured  at 
once,  and  the  spinal  marrow  suffers  at  the  same  time  a  commo- 
tion or  contusion  to  a  greater  or  less  degree:  and  much  less  dan- 
ger is  to  be  apprehended  from  the  fracture,  than  from  the  lesion 
of  that  substance.  In  fadt,  every  cause  that  will  fradtuire  the  ver- 
tebrae, must  give  a  commotion  to  the  spinal  marrow. 

It  is  thus  that  this  substance  suffers  from  a  fall  on  the  back 
from  an  elevated  situation,  or  from  the  aclion  of  a  bullet,  which 
strikes  against  the  vertebrae  after  having  penetrated  through  the 
soft  parts:  the  displaced  pieces  of  the  fractured  bones  might  in 
such  cases  press  on  that  substance,  or  the  fractured  splinters  might 
penetrate  into  it  after  having  pierced  the  dura  mater  and  its  other 
tunics.  The  laceration  of  its  vessels  might  also  produce  an  effu- 
sion, which  by  its  pressure  would,  as  effectually  as  any  other 
cause,  produce  a  paralysis  of  the  organs  whose  nerves  proceed 
from  the  parts  of  the  spinal  marrow  below  the  fracSture. 

The  variety  of  causes  which  may  give  rise  to  symptoms  analo- 
gous to  those  of  frafture  of  the  vertebrje,  render  it  difficult  to 
establish  a  diagnosis.  Yet,  when  a  person  has  fallen  on  his  back 
from  an  elevated  situation,  or  when  a  body  very  forcibly  impel- 
led, as  a  bullet  discharged  from  a  musket,  has  struck  that  part, 
if  a  fradture  has  taken  place,  some  derangement  of  the  spinal 
process  of  the  fractured  vertebra  may  be  observed,  by  an  atten- 
\ 


OF  THE  FRACTURES  OF  THE  VERTEBRA.      ^^ 

tive  examination  of  the  part  affefted.  Much  pain  is  caused  by 
pressing  on  that  process-,  the  inferior  extremities  are  paralysed, 
as  also  the  redlum  and  bladder;  the  patient  is  afflided  with  a  re- 
tention of  urine  and  faces,  or  with  an  involuntary  discharge  of 
the  latter. 

A  sack  of  flour,  weighing  300  tbs.  fell  on  the  back  of  the  neck 
of  a  porter  of  the  corn-hall,  in  a, moment  that  he  was  off  his 
guard,  and  laid  him  prostrate.  He  complained  of  a  very  acute 
pain  in  the  neck;  and  on  being  conveyed  to  La  Charite,  it  was 
found  that  the  spinal  process  of  the  seventh  vertebra  of  the  neck 
was  more  prominent  than  it  naturally  is.  The  superior  and  infe- 
rior extremities  were  paralytic,  respiration  became  difficult,  the 
bladder  and  reftum  ceased  to  perform  their  fun<Slions,  and  the 
patient  was  suddenly  cut  off.  On  opening  the  body,  a  fratSture 
of  the  seventh  vertebra  was  found,  with  derangement  of  a  frag- 
ment which  compressed  the  spinal  marrow. 

The  three  following  cases,  of  which  the  two  first,  like  the 
foregoing,  have  been  observed  at  Ln  Charke,  prove  that  the 
commotion  or  violent  distention  of  the  spine  can  produce  the  same 
symptoms  as  a  fracture' of  the  vertebrse. 

A  hosier  fell  into  a  shallow  ditch  on  his  loins;  the  commotion 
was  sulScient  to  produce  a  paralysis  of  the  inferior  extremities. 
After  his  death,  which  followed  from  the  fall,  no  disorganization 
could  be  perceived,  nor  any  effusion  either  in  the  cranium  or 
vertebral  canal. 

A  builder  fell  from  a  height  of  fourteen  feet,  and  remained 
for  sometime  senseless;  and,  on  recovering  from  that  situation, 
found  that  he  had  lost  the  use  of  his  inferior  extremities.  He  had 
at  the  same  time  a  retention  of  urine,  an  involuntary  discharge 
of  the  fieces,  and  some  disorder  in  the  function  of  respiration. 
Death  followed  on  the  twelfth  day  after  the  accident;  the  body 
was  opened,  and  the  vertebral  canal  was  found  to  contain  a  san- 
guineous serum,  the  quantity  of  which  was  sufficient  to  fill  a  lit- 
tle more  than  its  lower  half. 

A  man  excerclsing  himself  at  feats  of  activity,  distended  so 
much  the  intervertebral  ligaments,  that  he  was  instantly  seized 
with  an  acute  pain  in  the  part  so  distended,  by  the  strained  pos- 
ture which  he  had  assumed:  the  next  day,  the  inferior  extremi- 
ties, the  bladder,  and  reilum,  were  paralytic,  and  the  patient 
died  in  a  few  weeks. 

This  paralysis  of  the  inferior  extremities,  the  necessary  con- 
comitant of  fradlure  of  the  vertebrae,  and  of  any  lesion  of  the 
medulla  spinalis,  is  not,  in  itself,  a  mortal  affeftion;  but  the  pa- 
tient, losing  the  power  of  loco-motion,  and  being  obliged  to  1^ 


56  OF    THE    FRACTURES    OF    THE    VEiLTE^AM* 

perpetually  on  his  back,  soon  feels  a  troublesome  itching  in  the 
region  of  the  sacrum,  on  which  the  pressure  of  the  body  is  prin- 
cipally concentrated;  the  skin  of  this  part  becomes  inflamed,  and 
gangrene  ensues  to  a  greater  or  less  degree,  because  the  pressure 
on  that  part  intercepts  the  course  of  the  humours.  The  bone  is 
quickly  denuded,  the  ulcer  extends  rapidly,  and  consumes  the 
patient's  strength;  the  dissolution  is  accelerated  by  the  retention 
of  the  excrements  from  the  paralysis  of  the  redlum  and  bladder. 
The  catheter,  which  must  be  introduced  into  this  latter  organ  for 
the  purpose  of  evacuating  the  urine,  gives  admission  to  the  airj 
its  mucous  secretion  becomes  more  abundant,  and  its  substance 
thickened ;  a  slimy  matter  flows  out  with  the  urine,  and  the  pe- 
nis and  scrotum  become  oedematous,  &c.  A  slow  fever  succeeds 
these  symptoms;  and  the  patient,  however  robust  he  maybe,  falls 
in  a  few  weeks.  We  have  known,  however,  a  man  of  a  very  vi 
gorous  constitution,  to  have  survived  for  six  months  an  accident 
of  this  nature.  Examples  of  recovery  are  recorded,  but  they  are 
extremely  rare,  and  to  be  ascribed  to  the  secret  operations  of 
nature,  rather  than  to  the  efforts  of  art;  and  we  repeat,  that 
scarcely  one  in  thirty  recovers.  Almost  all  die  from  the  ex- 
haustion of  their  strengh,  by  slow  fever,  colliquative  diarrhoea,  &c. 

Any  attempt  at  setting  these  fraiStures,  would  be  not  only  use- 
less, but  dangerous,  by  the  straining  which  it  would  occasion. 
General  treatment  alone  can  be  had  recourse  to;  the  inflamma- 
tion and  obstruction  of  the  part  affedled  may  be  moderated  by 
cupping  and  scarification. 

If  the  patient  be  afl^e£led  with  a  flatulent  distension  of  the  abi^ 
domen,  vomiting,  hiccup,  .and  other  symptoms  of  that  nature, 
the  abdomen  may  be  rubbed  with  a  solution  of  two  drachms  of 
camphire,  in  a  sufficient  quantity  of  oil;  purgative  clysters  may 
be  also  given,  and  antispasmodic  medicines.  A  catheter  should 
be  allowed  to  remain  in  the  bladder,  with  its  external  orifice 
corked,  in  order  that  the  patient's  bed  may  not  be  wet:  the  ul- 
cerations of  the  sacrum  are  to  be  dressed  simply  with  pieces  c( 
linen  covered  with  cerate.  If  the  gangrenous  eschar  comes  ofi^, 
styrax  ointment  ought  to  be  applied;  and  if  the  patient  be  fortu- 
nate enough  to  recover  the  use  of  the  bladder,  rectum,  and  in- 
ferior extremities,  this  return  of  the  natural  forces  may  be  aided 
by  friiftions  with  tinilure  of  cintharldes,  on  the  course  of  the 
nerves  of  the  paralytic  organs;  and  as  soon  as  the  patient  is  able 
to  ride,  or  even  walk  with  the  aid  of  crutches,  he  will  find  it 
beneficial  to  drink  the  sulphureous  waters  of  Bourbon  or  Bare- 
ges. 


OF    THE    FRACTURES    OF    THE    STERNUM.  57 

Such  is  the  treatment  in  cases  of  fradlure  of  the  spine. 
Some  authors  recommend  trepanning  or  cutting  out  a  portion 
of  the  fra(ftured  bone,  when  the  compression  of  the  spinal 
marrow  by  effused  fluid,  or  its  disorganization  by  the  a(ftion  of 
a  spUnter,  is  suspected ;  but  exclusively  of  the  difficulty  of  that 
operation,  on  account  of  the  great  depth  of  the  intermediate 
soft  parts,  the  indication  is  never  sufficiently  evident  to  autho- 
rise it. 

If  a  fracture  of  the  vertebrae,  or  an  afFedlion  of  the  spinal 
marrow,  take  place  in  the  neck,  death  follows  rapidly.  This 
effeft  is  instantaneous,  if  the  lesion  be  as  high  as  the  origin  of 
the  cervical  nerves,  which  convey  nervous  energy  to  the  dia- 
phragm; for  that  organ  being  for  the  most  part  supplied  by 
these  nerves,  is  deprived  of  the  power  of  motion,  by  any 
considerable  lesion ~of  them. 

The  lesion  of  the  fourth  and  fifth  cervical  pair  of  nerves  by 
fra£ture,  supposes  that  accident  to  have  taken  place  in  the 
third  vertebra;  because  the  vertebral  nerves  originate  a  little 
higher  than  the  hole  by  which  they  pass  out  of  the  vertebral 
canal. 


CHAPTER  V. 


OF  THE  FRACTURES  OF  THE  STERNUM. 

THE  position  of  this  bone,  supported  laterally  by  the  flex- 
ible cartilages  of  the  ribs,  the  great  number  of  pieces  of 
which  it  consists,  unless  in  old  age,  its  thickness,  and  spongy 
texture,  co-operate  in  securing  it  against  fractures.  It  may, 
however,  be  fra<Slured,  and  in  two  different  ways.  The  frac- 
ture takes  place  generally  on  the  part  where  the  force  is  imme- 
diately applied;  but  it  may  be  occasioned  by  an  extention,  ope- 
rating on  both  extremities  of  the  bone. 

David  has  cited  (from  a  memoir  on  contrecoupSy  published 
under  the  name  of  Basile,  among  the  prize  essays  of  the  aca- 
demy) the  case  of  a  mason,  who,  in  falling  from  a  great  height, 
struck  against  a  cross-bar  which  intercepted  his  fall;  and  on 
8 


58     OF  THE  FRACTURES  OF  THE  STERNUM. 

v^hich  the  trunk  was  so  extended,  that  the  sternum  was  rup- 
tured transversely  by  the  violent  adtion  of  the  abdominal  and 
the  sterno-cleido-mastoidei  muscles.  In  cases  of  this  nature, 
very  rare  it  is  true,  the  fradture  must  be  simple,  and  without 
derangement  of  the  fragments,  or  affedlion  of  the  soft  parts. 
But  in  those  produced  by  the  immediate  aftion  of  an  external 
cause,  the  soft  parts  are  necessarily  affecHied,  and  the  fractured 
portions  may  be  impelled  into  the  mediastinum,  and  cellular 
texture,  so  as  to  wound  the  pericardium,  heart,  or  lungs. 

Solutions  of  continuity  of  the  sternum,  like  those  of  the 
cranium,  are  attended  with  a  greater  or  less  effusion  of  blood, 
mingled  with  a  medullary  substance,  which  is  very  abundant 
in  the  sternum  j  but  the  consequences  of  this  effusion  are  very 
different  in  the  two  cases.  The  slightest  effusion  within  the 
cranium,  gives  rise  to  the  most  alarming  symptoms,  and  causes 
sometimes  the  death  of  the  patientj  but  in  this  case,  on  the 
contrary,  however  abundant  that  effusion  may  be,  it  seldom 
occasions  dangerous  symptoms.  The  heart  and  lungs  being 
composed  of  a  substance  less  delicate  and  less  compressible  than 
the  brain,  suffer  little  or  no  inconvenience  from  this  effusion: 
besides,  the  capacity  of  the  thorax  is  variable,  and  may  on 
that  account  accommodate  itself  to  an  unusual  quantity  of 
fluid. 

A  simple  fradhire  is  ascertained  by  the  mobility  of  the 
"pieces:  that  which  is  compounded  with  contusion,  wound,  ef- 
fusion of  blood,  or  by  the  splinters  being  thrust  inward,  is 
easily  known  by  simple  inspeftion  of  the  part. 

A  simple  fra£lure  of  the  sternum  requires  no  other  treat- 
ment than  the  application  of  compresses,  repose,  and  a  proper 
position,  that  is,  on  the  back,  with  the  head  and  pelvis  raised; 
so  that  the  muscles  already  mentioned,  which  are  attached  to 
its  extremities,  may  be  in  a  relaxed  state.  But  in  cases  (which 
are  much  more  frequent)  of  frafture,  with  contusion,  wound, 
or  penetration  of  splinters  into  the  mediastinum,  the  patient 
should  be  bled,  and  confined  to  a  low  regimen;  poultices 
should  be  applied;  and  the  necessary  incisions  made  for  ex- 
tradVing  th6  splinters  from  the  mediastinum,  or  for  giving  issue 
to  the  effused  fluids.  It  is  but  very  seldom  necessary  to  tre- 
pan the  sternum  for  either  of  these  purposes ;  and  that  opera- 
tion becomes  necessary  only  when  that  part  of  the  sternum 
which  has  been  denuded,  becomes  affefled  with  caries,  the  fis- 
tula proceeding  from  which  would  be  incurable  by  any  other 
means.       Then    a  transverse   or   crucial  incision  should  be 


OF    THE    FRACTURES    OF    THE    RIBS.  59 

made  on  the  part  where  the  probe  points  out  the  course  of  the 
fistula.  The  part  affected  ought  to  be  laid  entirely  bare,  and 
completely  removed,  by  a  single  or  repeated  application  of  the 
instrument,  according  as  it  happens  to  be  more  or  less  exten- 
sive. The  instrument  ought  to  be  precisely  the  same  as  that 
used  for  the  head,  and  applied  with  all  possible  care,  lest,  by 
pressing  on  it  too  much,  it  should  be  driven  into  the  thorax, 
particularly  as  the  sternum,  naturally  capable  of  making  no 
great  resistance,  is  then  less  so  in  consequence  of  the  caries. 

The  appendix  xyphoides  is  not  susceptible  of  derangement 
backward 5  for,  though  violently  struck  and  driven  backward 
by  a  blow  on  what  is  vulgarly  termed  "  the  pit  of  the  stomach," 
yet  it  restores  itself  by  its  own  elasticity.  It  may  be  fractured 
in  aged  persons,  as  it  is  then  ossified;  but  even  in  that  case  the 
remedies  are  resolvents  and  emollients,  according  to  the  degree 
of  contusion.  However,  as  the  organs  contained  in  the  epi- 
gastric region  may  have  suffered  from  the  same  cause  that  pro- 
duces the  fracture,  it  might  be  prudent  to  draw  blood  in  pro- 
portion to  the  patients  strength,  and  to  confine  him  for  a  few 
days  to  the  antiphlogistic  regimen. 


CHAPTER  VI. 


OF  FRACTURES  OF  THE  RIBS. 

THE  ribs  are  placed  obliquely  on  each  side  of  the  thorax, 
and  terminate  in  a  cartilaginous  substance,  by  means  of 
which  they  articulate  with  the  sternum.  This  oblique  direc- 
tion, and  the  cartilaginous  termination,  render  them  but  little 
liable  to  fractures.  Some,  however,  are  more  exposed  to  frac- 
tures than  others;  thus  the  first,  or  superior,  being  protected 
by  the  bones  of  the  shoulder,  and  by  the  arm  itself,  when  it 
hangs  by  the  side,  and  the  lower  on  account  of  their  great 
flexibility,  are  less  liable  to  be  fraflured  than  the  middle  ones. 
Fractures  of  the  ribs  differ  from  one  another  by  the  part  of 
the  bone  in  which  the  frafture  takes  place,  by  the  direction  of 
the  fra<rture,  and  by  the  cause,  or  its  way  of  adting. 


60  OF    THE    FRACTURES    OF    THE    RIBS. 

Fra<^ures  of  the  ribs  happen  generally  near  the  middle  of 
the  bone;  and  this  is  the  case,  whether  one  or  more  of  them 
be  fradtured  at  the  same  time.  The  fradture  is  sometimes 
transverse,  at  other  times  oblique;  in  which  case  the  fracStu- 
red  portions  may  penetrate  the  skin  or  pleura,  according  to  the 
diredlion  they  take. 

As  the  cause  of  fradkures  of  the  ribs  may  a£l  either  on  their 
opposite  extremities,  or  on  their  middle  part,  a  distinction  of 
them  has  been  made  into  fraiStures  inwards  or  outwards.  In 
the  latter,  both  extremities  of  the  rib  are  at  the  same  time 
bent  towards  one  another,  so  that  the  convexity  of  the  rib  is 
increased,  and  the  fraflure  is  efFe£led  when  its  natural  extensi- 
bility is  exceeded.  This  frafture  is  not  without  some  reason 
termed  outward;  for  it  may  be  easily  conceived  that  the  exter- 
nal fibres  are  the  first  ruptured,  and  that  there  is  a  succession 
from  the  external  to  the  internal  side,  although  the  fradlure  be 
efFe(fted  almost  instantaneously.  This  species  of  fracture  is 
sometimes  observed  from  the  body  being  violently  pressed  be- 
tween a  wall  against  which  the  back  is  supported,  and  a  wheel 
of  a  carriage  which  presses  on  the  anterior  part  of  the  breast. 

The  fradlure  inwards  is  caused  by  a  body  strongly  impelleci 
against  the  middle  and  convex  part  of  the  nb;  or  when,  in 
falling,  that  part  strikes  against  a  hard  unyielding  body;  in 
which  case  the  frafturing  cause  tends  to  straighten  the  rib,  and 
consequently  the  fracture  commences  internally. 

In  whatever  manner  the  fracture  is  produced,  it  may  be 
complicated  with  contusion  or  external  wound.  The  sloped 
and  pointed  pieces  of  broken  bone  directed  internally,  may, 
by  lacerating  the  pleura  and  substance  of  the  lungs,  give  rise 
to  emphysema. 

Fractures  of  the  ribs  are  indicated  by  an  acute  pain  felt  in 
breathing.  However,  the  part  should  be  carefully  exami- 
ned, by  pressing  the  posterior  part  of  the  rib  inward,  and 
the  anterior  backward,  and  by  thus  ascertaining  if  there  ex- 
ists in  that  part  anjr  unnatural  motion,  or  if  any  crepitation 
can  be  produced.  In  fractures  of  the  ribs  the  derangement 
cannot  take  place  either  in  the  dire<5tion  of  the  diameter  of 
the  bone,  nor  in  that  of  its  axis  or  length.  The  ribs  being 
fixed  posteriorly  to  the  spine,  and  anteriorly  to  the  sternum, 
cannot  shorten,  as  the  interval  between  these  fixed  extremi- 
ties is  invariable.  Neither  can  the  derangement  take  place  by 
one  of  the  broken  pieces  becoming  higher  or  lower  than  the 
other,    because  the  same  muscles  are  attached  to  both  frag- 


OF    THE    FRACTURES    OF    THE    RIBS.  6l 

ments,  and  keep  them  at  the  same  distance  from  the  neigh- 
bouring ribs.  The  only  derangement  possible  is  the  angular, 
which  may  be  salient  internally  or  externally,  according  as  the 
fradture  is  in  one  or  other  of  these  diredlions.  Experiments 
made  on  the  dead  subjedl,  confirmed  the  reasoning  used  in 
this  case. 

Having  taken  off  the  muscles  which  cover  the  thorax,  I 
fractured  the  true  ribs  by  placing  a  great  weight  on  the  ster- 
num, the  body  being  laid  on  its  back.  This  fradlure  was  not 
attended  with  any  derangement.  If  the  weight  on  the  ster- 
num was  increased,  or  the  sides  of  the  thorax  pushed  forci- 
bly downward,  the  moveable  pieces  were  not  thereby  displa- 
ced, but  merely  compelled  to  form  with  their  contiguous  ex- 
tremities a  salient  angle  externally.  This  angle  was  salient 
internally,  in  a  subjeft  the  ribs  of  which  were  broken  by  a 
violent  blow  of  a  hammer  on  the  middle  part.  Whether  the 
projection  was  internal  or  external,  it  might  be  effaced  by 
merely  distending  the  cavity  of  the  thorax  as  in  inspiration.* 

The  derangement  cannot  then  take  place,  unless  the  mus- 
cles be  torn  by  the  violence  of  the  blow  which  caused  the  frac- 
ture, and  a  portion  of  the  rib  completely  detached. 

When  one  or  more  ribs  are  affefted  with  simple  fracture,  it 
will  be  necessary  merely  to  apply  on  the  fracStured  part  com- 
presses moistened  with  a  resolvent  fluid;  vvhich  compresses 
may  be  kept  on  by  means  of  a  bandage  placed  round  the  body, 
and  drawn  tight  enough  to  impede  the  motion  of  the  ribs,  and 
to  compel  the  patient  to  perform  respiration  chiefly  by  the 
descent  and  elevation  of  the  diaphragm..  When  the  fra^lure 
is  outward,  the  compresses  should  be  pretty  thick,  in  order  to 
i-epress  the  salient  angle.  When  it  is  inward,  they  should  be 
applied  on  the  extremities  of  the  rib  or  ribs,  in  order  to  force 
outward  the  fraftured  ends  which  have  a  tendency  to  point  in- 
wards towards  the  lungs.  The  bandage  round  the  body  is  pre- 
vented from  falling  downwards  by  means  of  a  seapulary  band- 
age. 

When  the  apparatus  does  not  confine  the  ribs  sufficiently, 
and  in  consequence  the  fradlured  parts  move  and  give  pain  in 
the  a6l  of  respiration,  the  quadriga  ought  to  be  applied  in  its 
stead.  This  bandage  commences  by  a  stellated  cross  on  the 
shoulder,  and  it  is  then  made  to  descend  on  the  thorax  in  folds; 
that  is,  each  succeeding  roll  covering  a  part  of  the  preceding. 

*  Memoirs  of  the  Society  of  Medical  EmuLtlon,  vol.  iii.  page  159. 


62  OF    FRACTURES    OF    THE    RIBS. 

In  order  to  render  it  more  secure,  it  may  be  fastened  with  pins 
in  different  places.  It  is  seldom  necessary  to  raise  the  apparatus 
in  order  to  view  the  state  of  the  parts  underneath,  as  the  ec- 
chymosis  disappears  of  itself  in  a  very  few  days. 

When  the  violence  has  been  considerable,  and  the  lungs  have 
been  contused  or  lacerated  by  the  pieces  of  bone,  the  patient 
suffers  much  pain,  has  acute  fever,  thirst,  and  difficulty  of 
breathing;  in  short,  all  the  symptoms  of  an  inflammation  of 
the  lungs.  In  this  case  the  treatment  ought  to  be  the  same  as 
in  pneumonia;  among  the  remedies  for  which,  copious  and  re- 
peated bleedings  hold  the  first  rank. 

With  respe£t  to  the  emphysema,  which  is  the  name  given 
to  a  tumour  formed  by  the  admission  of  air  into  the  cellular 
texture,  it  may  be  produced  by  a  fracflure  of  the  ribs  in  the 
following  manner.  Let  us  suppose  that  a  pointed  piece  of  bone, 
impelled  into  the  thorax,  lacerates  the  pleura,  and  vesicular 
texture  of  the  lungs,  and  that  the  air  which  escapes  through 
the  lungs  in  the  aft  of  inspiration  is  received  between  them  and 
the  pleura  in  the  cavity  of  the  thorax.  In  the  succeeding  ex- 
piration, the  cavity  of  the  thorax  becomes  diminished  ;  the  air 
contained  in  it  being  compressed,  endeavours  to  escape  by  the 
part  where  it  finds  least  resistance,  that  is,  by  the  wound  of 
the  pleura;  but  as  there  may  exist  no  external  wound  in  the 
thorax,  or  even,  though  there  did,  should  it  be  narrow  and 
sinuous,  the  air  could  not  escape  externally;  it  must  therefore, 
make  its  way  into  the  neighbouring  cellular  texture,  which  it 
distends  and  tumefies.  This  effect  of  a  single  inspiration  and 
expiration,  is  increased  by  a  second,  a  third,  &c.  to  the  degree 
that  the  air  may  pervade  the  cellular  texture  of  the  whole  body, 
except  the  palms  of  the  hands  and  soles  of  the  feet ;  because 
in  these  parts  certain  ligamentous  processes  unite  the  integu- 
ments so  closely  to  the  subjacent  aponeurosis,  that  the  in- 
terjacent cellular  texture  cannot  admit  the  air.  A  case  of 
emphysema  has  been  observed,  in  which  the  whole  body 
had  acquired  a  most  enormous  volume:  the  anterior  side  of 
the  thorax  was  eleven  inches  deep.  If  something  be  not 
done  to  stop  the  progress  of  the  emphysema,  the  air,  after 
having  filled  the  cellular  texture  under  the  skin,  makes  its 
way  along  the  vessels  into  the  substance  of  the  viscera,  the 
forms  and  funftions  of  which  it  deranges,  and  in  a  short  time 
destroys  life.  Happily  this  accident  rarely  succeeds  to  a  frac- 
ture of  the  ribs.  Citizen  Boyer  has  seen  only  one  example  of 
it,  which  was  that  of  a  labourer,  who  received  his  death  from 
the  explosion  of  the  powder-mills  of  Crenelle  in  1793.    Le-r 


OF    THE    FRACTURES    OF    THE    RIBS.  6^ 

dran,  in  his  24th  Surgical  Observation,  makes  mention  of  the 
case  of  a  coachman,  in  whom  a  fra^lure  of  the  fifth  true  rib,  in 
consequence  of  a  kick  from  a  horse,  was  followed  by  an  em- 
physema, in  which  the  integuments  were  inflated  to  the  depth 
of  four  inches. 

In  cases  of  this  nature,  it  is  necessary  to  follow  the  example 
of  that  able  pra<fi:itionerj  that  is,  to  apply  pyramidal  compresses 
on  the  part  where  the  emphysema  commences ;  the  compresses 
should  be  impregnated  with  some  resolvent  liquid,  and  braced 
according  as  the  tumour  collapses. 

If  the  emphysema,  already  far  advanced,  be  still  making 
progress,  it  will  be  necessary  to  make  an  incision  into  that  side 
of  the  thorax  where  the  fracSture  of  the  ribs,  with  lesion  of 
the  pleura  and  lungs,  was  suspe(n;ed:  the  air,  finding  free  egress 
though  this  wound,  will  no  longer  pass  into  the  cellular  texture. 
The  validity  of  this  precept  will  be  rendered  evident,  by  con- 
sidering that  emphysema  never  follows  large  incised  wounds  of 
the  thorax;  and  that,  on  the  contrary,  it  is  frequently  compli- 
cated with  narrow  and  oblique  wounds  made  by  a  pointed  in- 
strument, such  as  a  small  sword. 

Whatever  means  be  adopted  for  arresting  the  progress  of  the 
emphysema,  the  air  which  has  already  passed  into  the  cellular 
texture,  loses  its  elasticity;  its  component  parts  combine  with 
the  fat  and  lymph  contained  in  the  cellular  substance,  and  the 
tumefied  parts  return  gradually  to  their  former  size.  This  ter- 
mination of  the  disease  may  be  accelerated  a  little  by  making 
incisions  in  different  parts  of  the  body,  and  applying  resolvents 
over  them. 

The  cartilages  of  the  ribs  cannot  be  broken  before  they  are 
ossified.  As  long  as  they  retain  their  cartilaginous  stru(Sture, 
and  remain  supple  and  flexible,  though  they  may  be  bent  in 
towards  the  lungs,  yet,  being  eminently  elastic,  they  return 
to  their  natural  shape  as  soon  the  external  force  is  removed. 
Nothing,  then,  can  be  more  ridiculous,  nothing  more  dange- 
rous than  the  absurd  pradlice  of  bone-setters  for  raising  what 
they  call  "  depressed  ribs."  Their  greasy  and  irritating  plasters 
ought  also  to  be  proscribed;  for  such  topical  applications  can 
only  irritate  the  skin,  excite  an  erysipelatous  inflammation, 
augment  the  pain  which  the  contusion  produces;  and,  by  inspi- 
ring a  false  security,  cause  the  consequences  of  the  affection  to 
be  neglefted.  When  the  ossified  cartilages  are  fractured  in  an 
old  person,  the  treatment  is  the  same  as  that  for  a  fra^re  of 
any  other  part  of  the  rib. 


64 


CHAPTER  VII. 
OF  FRACTURES  OF  THE  BONES  OF  THE  PELVIS. 


SECTION   I. 


Of  Fractures  of  the  Sacrum, 

THIS  bone  is  not  much  exposed  to  be  fra£lured:  it  is  thick 
and  of  a  spongy  texture,  deeply  situated,  and  covered  by 
a  great  depth  of  soft  parts,  which  deaden  any  force  that  tends 
to  fracture  it  by  afting  on  its  great  diameter,  or  transmit  that 
force  to  the  ossa  innominata,  between  which  it  is  fixed  as  a 
wedge.  Some  powerful  cause,  such  as  the  fall  of  a  very  heavy 
body,  or  the  passage  of  a  carriage-wheel  on  the  convex  side  of 
that  bone,  can  alone  fradlure  it:  it  may  be  also  fradtured  by  a 
fall  on  the  same  part  from  a  great  height.  Thus  we  find  that 
these  fradlures  of  it,  which  may  have  different  directions,  and 
exist  in  difi^erent  parts,  are  always  produced  by  a  force  which 
has  crushed  the  bone.  No  muscle  tends  to  derange  by  its  con- 
tractions the  position  of  the  broken  portions;  and  the  fradtures 
are,  therefore,  dangerous  only  by  the  contusion  which  the 
parts  contained  in  the  pelvis  may  suffer;  and  which,  by  produ- 
cing effusion  of  blood,  inflammation,  and  abscesses,  may  de- 
stroy the  patient. 

The  treatment  of  these  fra£bures  consist  simply  in  tying  a 
napkin  round  the  pelvis,  an  emollient  poultice  being  previously 
applied  on  the  fradtured  part.  Inflammation,  and  its  concomi- 
tants, are  prevented  by  bleeding,  low  diet,  and  other  means, 
of  which  mention  shall  be  made  in  treating  of  fradlures  of  the 
ossa  innominata. 


OF    FRACTURES    OF   THE   OS    COCCyOIS,  65 


SECTION   II. 


»  Of  FraElures  of  the  Os  Coccygis. 

This  little  bone,  though  much  slighter  than  the  sacrum,  is, 
however,  not  so  often  fradlured,  because  it  offers  no  point  on 
which  an  external  force  can  a6t  with  advantage  -,  and  because, 
by  its  mobility,  it  can  yield  to  any  impelled  force,  and  return 
again  to  its  natural  position. 

When  it  is  fradlured,  as  by  a  fall  on. the  buttocks,  the  pain 
which  ensues,  and  which  augments  by  walking,  indicates  the 
existence  of  the  fracture.  Some  fibres  of  the  glutsei  are  attach- 
ed to  this  bone,  and  by  moving  the  fragments  one  on  the  other, 
in  the  a£t  of  walking,  produce  the  painful  sensation;  this  sen- 
sation may  however,  depend  on  the  contusion,  and  cannot, 
therefore,  be  considered  a  proof  of  the  existence  of  the  fradhire. 

This  kind  of  fra6hire  does  not  require  any  apparatus  for  keep- 
ing the  broken  pieces  in  a  just  position;  although  the  levatores 
ani  may  draw  the  anterior  fragment  a  little  forward.  Resolvents, 
or  emollient  poultices,  as  the  circumstances  may  require,  ought 
to  be  applied;  it  may  be  also  necessary  to  take  away  some  blood; 
and  the  most  perfedt  repose  should  be  enjoined,  in  order  that 
the  action  of  the  glutsei  muscles  may  not  interrupt  the  conso- 
Hdation. 

It  is  not  amiss  to  remark  here,  that  falls  on  the  buttocks  are 
frequently  attended  with  bad  consequences,  when,  from  a  fool- 
ish bashfulness,  the  patient  conceals  his  sufferings,  or  refuses 
to  submit  to  examination  by  a  surgeon. 

Thus,  the  sister  of  a  celebrated  aftor,  who  refused  to  submit 
to  examination,  although  she  suffered  much  pain  in  the  region 
of  the  coccyx,  allowed  an  abscess  to  form  in  that  part,  on 
opening  which,  the  os  coccygis  was  found  fraftured,  and  af- 
fefted  with  caries,  as  was  also  the  inferior  extremity  of  the 
sacrum. 


66        OF    FRACTURES    OF    THE    OSSA    INNOMINATAo 


SECTION   III. 


Of  FraBures  of  the  Ossa  Innominata. 

Fractures  of  these  bones  are  not  frequent,  but  never  take 
place  without  an  attendant  contusion  of  the  external  soft  parts, 
and  sometimes  of  the  parts  contained  in  the  pelvis.  Different 
parts  of  these  bones  may  be  fra<ftured,  and  the  fracture  may  run 
in  different  dire£lions.  The  anterior  and  superior  spinal  process 
of  the  OS  ilium  may  be  fradtured,  and  with  it  the  adjacent  part  of 
the  ridge  of  that  bone;  of  which  we  have  seen  an  example  in 
the  case  of  a  farrier,  who  received  a  kick  from  a  horse  on  that 
part.  The  ossa  pubis  and  ossa  ischia,  being  protected  by  the 
inferior  extremities,  are  less  frequently  fradlured  than  the  ilia. 
No  derangement  takes  place  In  the  fradlured  portions,  whatever 
may  be  the  dire(ftion  of  the  fradlure;  not  even  in  fradlures  of 
the  ossa  ilia,  which  is  the  more  to  be  wondered  at,  as  these 
bones  are  very  thin:  this  immobility  of  the  broken  parts  is  to  be 
ascribed  to  the  thick  and  strong  muscles  which  are  attached  in- 
ternally and  externally  to  the  broken  portions. 

But  these  fractures  are  rendered  very  dangerous  by  the  ex- 
travasation of  blood  and  medullary  substance  into  the  cellular 
texture  of  the  pelvis,  and  by  the  contusion  of  the  parts  which 
are  contained  in  it.  When  the  pelvis  has  been  fradhired  by 
the  passage  of  a  wheel,  by  the  fall  of  a  heavy  body  on  it,  by  a 
fall  on  the  breech,  the  patient  is  entirely  disabled  from  walking. 
If  the  pelvis  be  pressed  in  opposite  directions,  the  motion  of 
the  broken  pieces  on  one  another  will  be  perceived,  a  crepita- 
tion will  be  heard,  and  some  inequalities  arising  from  the  de- 
rangement of  the  bones  may  be  clearly  distinguished.  The 
existence  of  the  frafture  being  ascertained,  the  surgeon's  first 
care  will  be  to  obviate  the  consequences  of  inflammation  by  co- 
pious and  repeated  blood-letting.  If  inflammation  has  already 
taken  place,  it  must  be  combatted  by  the  same  means;  at  the 
same  time  topical  remedies  are  to  be  applied.  The  pelvis  ought 
to  be  surrounded  with  a  napkin  folded  in  the  shape  of  a  band- 
age for  the  trunk;  and  in  cases  where  the  contusion  is  exces- 
sive, the  bones  splintered  and  loose,  and  the  neighbouring 
parts  disorganized,  as  it  would  be  impossible  for  the  patient  to 
move  or  go  to  stool  without  suffering  the  most  excruciating 


OF    FRACTURES    OF    THE    OSSA    INNOMINATA.         67 

pain,  it  will  be  necessary  to  pass  a  piece  of  strong  girth  web 
under  the  pelvis,  the  corners  of  which,  coUedled  into  one,  are 
to  be  fastened  to  a  pully  suspended  from  the  top  of  the  bed: 
by  means  of  this  pully,  the  patient  may  raise  himself  with  very 
little  effort.  Citizen  Boyer  invented  this  apparatus  for  a  pa- 
tient affected  in  the  manner  we  have  just  described:  he  was 
able  to  raise  himself  with  the  greatest  ease,  and  to  such  a  de- 
gree as  that  a  flat  vessel  might  be  placed  under  him.  It  is  ap- 
plicable to  all  cases  of  compound  fradture  of  the  inferior  ex- 
tremities, in  which  it  may  be  necessary  to  raise  the  patient  fre- 
quently. 

However  judicious  the  treatment,  and  well-dire£led  the  an- 
tiphlogistic remedies,  the  inflammatory  symptoms  will  generally 
be  so  intense,  that  an  excessive  suppuration  will  be  the  conse- 
quence; and  large  abscesses  will  form,  in  which  the  pus  will 
stagnate,  in  consequence  of  the  great  quantity  of  cellular  tex- 
ture in  that  part  of  the  body. 

Sometimes,  however,  the  patient  recovers,  the  effused  blood 
is  absorbed,  and  the  inflammation  ends  in  resolution.  It  may 
happen  too,  that  detached  splinters  shall  give  rise  to  subsequent 
abscesses,  as  in  a  case  related  by  Marety  in  the  Memoirs  of  the 
Academy  of  Dijon,  of  a  woman  who  had  had  a  fradlure  of  the 
pubis,  and  from  whom  he  extra<Sl:ed  a  large  portion  of  that 
bone  through  an  abscess  formed  hi  the  labia  pudendi. 

Desault  in  giving  an  exit  to  a  coHe£lion  of  urine  which  had 
taken  place  from  a  frafture  of  the  pelvis,  found  a  splinter  which 
he  extracted  from  the  bottoin  of  the  wound. 

If  the  bladder  be  perforated  by  a  splinter,  this  should  be  ex- 
tracted, and  a  catheter  introduced  into  the  bladder,  in  order  to 
prevent  the  accumulation  of  urine,  and  its  consequent  effusion 
into  the  abdominal  cavity.  Chopart  gives  an  example  in  Vol.  II. 
of  his  Treatise  on  the  Diseases  of  the  Urinary  Passages,  which 
justifies  this  pradlice. 

It  may  be  said,  that  artificial  means  are  but  of  small  effect 
in  fractures  of  the  pelvis,  that  the  treatment  must  be  general, 
and  that  even  this  is  not  always  efficacious,  when  (as  most  ge- 
nerally happens)  the  fracture  is  complicated  with  lesion  of  the 
external  soft  parts  and  contents  of  the  pelvis. 


CHAPTER  VIII. 


OF  FRACTURES  OF  THE  SCAPULA. 

THIS  bone  is  seldom  fraftured,  because,  being  suspended 
on  the  superior  lateral  and  posterior  part  of  the  trunk, 
and  moveable  in  that  situation,  it  yields  easily  to  any  force  im- 
pelled against  it.  All  its  parts  are  not,  however,  equally  se- 
cure from  fra£ture.  The  acromion,  vsrhich  terminates  exter- 
nally its  spinal  process,  and  advances,  like  an  arch,  over  the 
head  of  the  humerus,  forming  thus  a  part  of  the  shoulder,  is 
easily  fradlured,  because,  being  but  thin,  and  lightly  covered 
■wieh  soft  parts,  it  yields  easily  to  a  force  pressing  it  downward, 
where  it  is  supported  only  by  cellular  texture.  The  inferior 
angle  of  the  scapula  is,  after  the  acromion,  that  part  of  it 
which  is  most  easily  fractured.  The  coracoid  process  is  too 
deeply  seated  to  be  frad^tured,  except  in  the  case  of  gun-shot 
■wound:  that  is  the  only  one  in  which  J.  L.  Petit  met  an  exam- 
ple of  it.  It  has  also  been  fraftured  by  the  fall  of  a  heavy 
body  on  it;  in  this  case,  the  soft  parts  were  excessively  contu- 
sed, and  the  patient  died. 

Fra<Slures  of  the  scapula,  whether  passing  from  its  superior 
to  its  inferior  edge,  across  the  spinal  process,  or  from  its  ex- 
ternal to  its  internal  edge,  are  always  accompanied  with  con- 
siderable contusion,  because  the  fracturing  cause  must  have 
afted  immediately  on  the  part.  The  first  mentioned,  or  lon- 
gitudinal fraftures,  are  less  frequent  than  the  transverse.  The 
vertical  diameter  being  the  greater,  a  greater  force  would  of 
course  be  necessary  to  fracture  the  bone  in  that  direction  than 
in  the  other.  Longitudinal  fradtures  cause  but  very  little  de- 
rangement, because  the  muscles  which  are  attached  to  the  surface 
of  the  scapula,  prevent  the  separation  of  the  fractured  portions. 
In  transverse  fradtures,  the  derangement  is  not  quite  so  trifling. 
The  serratus  anticus  major  draws  forward  the  lower  portion, 
to  which  it  is  principally  attached.  The  rhomboides  may  also 
concur  in  producing  this  derangement,  which  is  always  great 
enough  to  be  perceived  by  the  fingers  drawn  along  the  base. 


OF  FRACTURES  OF  THE  SCAPULA.        69 

or  internal  side,  where  the  inequality  will  be  produced.  In 
fra<Stures  of  the  acromion  and  inferior  angle,  the  derange- 
ment is  much  more  considerable.  The  weight  of  the  arm,  and 
the  contradlion  of  the  deltoid  muscle,  draw  downward  the 
acromion,  at  the  same  time  that  the  trapezius  and  levator  sca- 
pulae draw  the  rest  of  the  bone  upward  and  backward.  The 
serratus  anticus  major  draws  forward  the  lower  angle,  the  rest  of 
the  scapula  remaining  in  its  natural  situation  ;  or  if  the  angular 
portion  be  considerable,  the  teres  major  and  some  fibres  of  the 
latissimus  dorsi  contribute  to  its  derangement  forward  and  up- 
ward. 

If  the  coracoid  process  is  fra£hired,  the  peftoralis  minor, 
the  coraco-brachialis,  and  short  portion  of  the  biceps,  concur 
in  drawing  it  forward  and  downward. 

These  different  fraiftures  may  be  ascertained  by  the  following 
signs:  the  longitudinal  ones  are,  however,  not  easily  distin- 
guished. If  much  pain  be  felt  in  consequence  of  a  blow  or 
fall  on  the  shoulder,  the  part  should  be  examined;  for  by  feel- 
ing the  scapula,  and  pressing  it  in  different  direcStions,  the  mo- 
tion of  the  broken  pieces,  and  crepitation,  may  be  perceived, 
particularly  if  the  patient  be  not  fat,  and  an  inflammatory 
swelling  has  not  as  yet  supervened.  Transverse  fractures  are 
more  easily  distinguished  by  the  inequality  which  they  cause  in 
the  basis  of  the  scapula,  by  the  mobility  of  the  pieces,  which 
may  be  moved  in  opposite  diretStions,  by  seizing  in  one  hand 
the  inferior  angle,  and  in  the  other  the  acromion  and  spinal 
process. 

The  derangement  is  so  considerable  in  a  frafture  of  the  in- 
ferior angle,  that  it  is  impossible  to  be  mistaken,  or  to  overlook 
it;  this  part  being  quite  detached,  remains  motionless,  although 
the  rest  of  the  scapula  should  be  moved. 

The  pain  which  always  attends  the  frafhire  of  the  acromi- 
on, and  which  is  increased  by  the  motions  of  the  arm,  the  al- 
teration in  the  form  of  the  shoulder,  and  the  mobihty  of  the 
acromion,  v/hich  has  descended,  and  which  ascends  when  the 
elbow  is  raised  close  to  the  trunk,  are  the  distindive  marks  of 
this  frafture.  The  small  quantity  of  soft  parts  covering  the 
acromion  renders  the  discovery  of  it  very  easy. 

The  contusion  which  constantly  attends  fractures  of  the  sca- 
pula, whatever  may  be  the  part  fra(ftured,  is  the  most  dan- 
gerous symptom.  Abscesses  have  sometimes  formed  in  the 
fossa  subscapularis  in  consequence  of  fractures  of  the  scaoula, 
and  effusions  have  taken  place  in  the  thorax,  when  the  frac- 


70  or    FRACTURES    OF    THE    SCAPULA. 

taring  cause  has  a^led  with  such  violence  as  to  extend  the  con-  • 
tusion  to  the  parietes  of  that  cavity. 

When  the  scapula  is  fractured  longitudinally,  or  transverse- 
ly, near  its  spinal  process,  k  is  merely  necessary  to  fix  the  arm 
to  the  side  of  the  trunk  by  means  of  a  bandage,  vphich  in- 
cludes the  arm  and  trunk,  and  which  descends  from  the  shoul- 
der to  the  elbow.  The  steadiness  of  this  bandage  is  still  fur- 
ther increased  by  applying  a  roller  which  embraces  the  shoul- 
der and  the  elbow.  Bv  binding  the  arm  in  this  manner,  the 
motions  of  the  shoulder  are  prevented,  because  its  motions  are 
only  concomitant  to  those  of  the  arm.  This  apparatus,  or 
that  of  Desault  for  the  fracture  of  the  scapula,  with  the  omis- 
sion of  the  cushion  for  the  arm-pit,  is  by  much  preferable  to 
that  by  which  the  hand  of  the  side  affefted  is  placed  on  the 
shoulder  of  the  opposite  side — a  situation  which  is  unnatural 
and  fatiguing,  and  which  cannot  be  long  persevered  in. 

As  the  inferior  angle,  when  separated  by  firaclure  from  the 
rest  of  the  bone,  is,  like  the  condyloid  process  of  the  jaw, 
little  susceptible  of  being  acted  on  by  any  means  in  our  power, 
it  will  be  necessary  to  aft  o>  the  scapula  itself,  to  push  it 
downward  and  forward  toward  the  inferior  fragment,  which 
the  serratus  anticus  major  has  drawn  in  that  diredlion. 

In  this  case  too,  it  is  on  the  arm  that  it  will  be  necessary  to 
act,  in  order  to  move  the  scapula.  The  arm  is  to  be  pushed 
inward,  downward,  and  forward,  the  fore-arm  being  half 
bent:  it  must  be  kept  in  this  position  by  a  circular  bandage  se- 
ven yards  long.  It  will  be  proper  at  the  same  time  to  aft  on 
the  angular  detached  portion  by  means  of  compresses,  which 
may  be  pressed  backward  by  some  rounds  of  a  bandage,  and 
thus  brought  in  contaft  with  the  rest  of  the  bone.  The  arm 
may  be  supported  by  a  sling  knotted  on  the  opposite  shoulder. 

The  acromion,  when  fraftured,  is  drawn  downward  and 
outward  by  the  aftion  of  the  deltoides,  at  the  same  time  that 
the  rest  of  the  bone  is  drawn  upward  and  backward  by  the 
trapezius  and  levator  scapulae.  This  frafture  is  set  by  raising 
the  arm  in  such  a  manner  as  that  the  head  of  the  humerus 
may  push  upward  the  acromion,  which  has  descended,  and 
which  naturally  covers  it  like  an  arched  roof;  at  the  same  time 
an  assistant  pushes  the  scapula  forward  and  downward  in  a  di- 
reftion  opposed  to  that  which  is  given  the  arm.  In  order  that 
the  parts  may  remain  in  this  situation,  it  will  be  necessary  that 
the  aftion  by  which  they  have  been  placed  in  it  be  perpetuated 
by  bandages;  that  is,  that  the  arm  be  supported  parallel  to  the 


OF  FRACTURES  OF  THE  SCAPULA.        7 1 

trunk,  and  that  the  shoulder  be  pressed  downward  at  the  same 
time. 

To  effe£l  this,  a  circular  bandage  is  applied  round  the  trunk 
and  arm,  and  afterwards  made  to  ascend  from  the  elbow 
to  the  shoulder,  and  mce  versa.  In  this  last  direiSlion,  the 
bandage  has  the  advantage  of  securing  on  the  shoulder  the 
compresses,  moistened  with  a  repellent  liquid,  of  raising  the 
humerus  against  the  acromion,  of  which  it  ought  to  be  the 
support  while  nature  efFe£ls  the  consolidation,  and  pressing 
down  the  scapula  to  the  level  of  the  acromion.  This  bandage, 
like  all  those  of  the  thorax,  is  very  liable  to  be  displaced,  on 
account  of  the  motion  of  the  thorax;  it  ought,  therefore,  to 
be  frequently  reapplied,  never  forgetting  on  these  occasions  to 
have  the  elbow  raised,  and  the  shoulder  pressed  down. 

Although  fractures  of  the  scapula  consolidate  in  the  ordinary 
time  of  from  thirty-five  to  forty  days,  yet  in  those  of  the  acro- 
mion it  will  be  necessary  to  continue  the  bandage  a  little  longer: 
not  that  the  generation  of  callus  is  slower  in  that  part  of  the 
bone  than  in  any  other,  but  because  that  process  is  acted  on  by 
two  strong  muscles,  which  might  rupture  the  callus,  if  expo- 
sed to  their  action  before  it  had  acquired  a  great  degree  of  so- 
lidity. 

To  these  mechanical  means  general  remedies  may  be  ad- 
ded, such  as  blood-letting,  &c.  The  consequence  of  these  frac- 
tures are  seldom  dangerous.  A  case  has  been  given,  however, 
in  which  the  cellular  texture  which  unites  the  subscapularis 
muscle  to  the  depression  of  that  name,  became  inflamed,  sup- 
purated, and  a  deep-seated  abscess  was  formed,  for  which  it 
was  found  necessary  to  trepan  the  scapula.  A  person  received 
a  thrust  of  a  sword  in  the  shoulder;  the  weapon,  after  having 
penetrated  the  integuments  and  infraspinatus  muscle,  pierced 
also  the  scapula,  and  wounded  the  subscapularis  muscle.  The 
inflammatory  symptoms  were  intense,  and  an  abundant  sup- 
puration took  place.  In  order  to  stop  the  suppuration,  Mare- 
chal  enlarged  the  fistulous  orifice  by  trepanning  the  scapula. 
The  operation  was  attended  with  success,  as  we  learn  from  the 
author  of  its  eulogium,  which  is  found  at  the  commencement 
of  the  second  volume  of  the  Memoirs  of  the  Academy  of  Sur- 
gery. 


72  OF    FRACTURES    OF    THE    CLAVICLE. 


CHAPTER  IX. 


OF  FRACTURES  OF  THE  'CLAVICLE. 

MANY  causes  conspire  to  render  the  clavicle  liable  to 
fradture:  it  is  long  and  slender,  supported  in  Its  mid- 
dle part  only  by  cellular  texture;  and  protected  externally  but 
by  a  very  thin  covering  of  soft  parts.  But  Its  fundtions  con- 
tribute much  more  than  these  circumstances  to  render  the  frac- 
ture of  it  frequent.  It  serves  to  keep  the  scapula  at  a  proper 
distance  from  the  sternum,  and  adls  as  a  point  d'appui  to  the 
humerus,  every  impulse  of  which  it  receives  and  transmits  to 
the  sternum. 

A  frafture  of  this  bone  may  take  place  in  any  part  of  its 
length,  but  it  most  frequently  happens  near  its  middle,  because 
its  curvature  is  greatest  at  that  part.  Sometimes,  but  rarely,  it 
takes  place  near  the  extremity,  articulated  with  the  scapula. — 
Fractures  of  it  may  be  transverse  or  oblique ;  simple,  or  com- 
plicated with  contusion,  wound,  or  detached  splinters — differ- 
ences which  depend  on  the  action  of  the  fra(Sluring  cause.  A 
blow  on  the  shoulder,  and  of  sufficient  momentum^  will,  as  it 
a£ls  directly,  fradlure  the  bone  in  that  part  on  which  it  is  in- 
£li(5led,  and  will  at  the  same  time  lacerate  or  eontund  the  soft 
parts.  A  comminutive  fracture  may  be  produced  by  this 
means;  and  if  the  violence  be  sufficiently  great,  the  subclavian 
vessels,  and  nerves  which  lie  between  the  clavicle  and  first  rib 
may  be  torn;  and  a  paralysis  of  the  arm  produced:  this  affec- 
tion frequently  follows  the  fall  of  a  heavy  body  on  the  shoul- 
der. 

If  the  frasSlure  be  caused  by  contre-coup,  in  which  case  the 
fradluring  force  is  immediately  applied  to  the  ends  of  the  bone, 
it  is  not  necessarily  complicated  with  contusion.  A  fracture 
may  be  occasioned  in  this  way  by  a  fall  on  the  point  of  the 
shoulder,  or  on  the  hands,  the  arms  being  extended.  It  may 
happen,  however,  in  this  case,  that  the  clavicle,  pressed  very 
forcibly  against  the  sternum,  may  be  bent  much  "beyond  its 
natural  curve,  and  fradlured  so  obliquely,  that  the  broken  por- 
tions shall  pierce  through  the  integuments. 


OF    FRACTURES   OF    THE    CLAVICLE,  73 

Frailures  of  the  clavicle  are  generally  attended  with  de- 
rangement of  the  broken  portions,  those,  however,  excepted, 
which  take  place  near  the  extremity  articulated  with  the  sca- 
pula, and  within  the  coraco-clavicular  ligaments.  Although 
the  bone  be  very  slender  in  this  part,  yet  it  is  so  strongly  at- 
tached to  the  scapula  by  these  fibrous  productions,  that  the 
derangement  is  scarcely  sufficient  to  indicate  the  existence  of 
the  fraiSlure. 

The  mechanism  of  the  derangement  of  the  pieces  is  easily 
understood:  the  external  portion  is  that  which  is  always  de- 
ranged, because  the  internal,  retained  in  its  articulation  by  the 
costoclavicular  ligaments,  and  drawn  in  opposite  diredlions  by 
the  sterno-cleido-mastoideus,  and  peCloralis  major,  is  immova- 
bly fixed.  The  external  fragment,  on  the  contrary,  being 
weighed  down  by  the  arm,  and  drawn  in  the  same  direction 
by  the  a6lion  of  the  deltoides,  and  being  at  the  same  time 
drawn  forward  and  inward  by  the  pedloralis  major,  is  carried 
under  the  internal  portion,  which  forms  an  eminence  over 
it.  ^ 

From  the  moment  that  the  fradlure  of  the  clavicle  allows  the 
shoulder  to  approach  the  sternum,  the  arm  falls  on  the  fore 
part  of  the  breast;  and  the  patient  resembles  in  that  particular, 
an  animal  without  a  clavicle. 

One  of  the  principal  signs  of  fradlure  of  the  clavicle,  is  the 
impossibility  which  the  patient  finds  of  applying  the  hand  of 
the  side  afFedted  to  his  forehead,  because  that  a6l  requires  a 
semicircular  motion  of  the  humerus,  which  cannot  be  perform- 
ed if  that  bone  has  not  a  firm  point  d^apptii.  If  the  patient 
attempts  this  motion  of  the  arm,  it  may  be  remarked  that  he 
merely  bends  the  fore-arm  and  inclines  his  head,  in  order  to 
bring  the  hand  and  forehead  into  contadl.  In  addition  to  this 
sign,  it  will  be  observed,  that  the  shoulder  and  superior  extre- 
mity are  placed  more  anteriorly  on  the  breast  and  nearer  the 
sternum,  than  in  their  natural  state,  or  than  those  of  the  op- 
posite side.  The  patient  leans  to  the  fra£lured  side;  and  if 
the  part  be  examined  before  a  swelling  and  inflammation  has 
come  on,  the  motion  of  the  pieces  on  one  another  may  be 
perceived,  and  the  proje6lion  formed  by  the  end,  generally  of 
the  internal  portion,  will  be  evident.  A  crepitation  may  be 
produced  by  the  motion  of  the  shoulder,  but  not  without 
causing  great  pain.  These  signs,  independently  of  preceding 
circumstances,  establish  clearly  the  diagnosis  of  fradlures  of 
the  clavicle. 

10 


74  OF    FRACTURES    OF    THE    CLAVICLE. 

If  Ihe  soft  parts  have  suffered  no  extraordinary  contusion,  a 
fracture  of  the  clavicle  is  not  dangerous;  but  if  the  fracture  be 
comminutive,  the  soft  parts  lacerated,  and  the  nerves  of  the 
brachial  plexus  injured,  much  danger  may  result  from  it. 

For  no  fracture  have  so  many  bandages  and  so  much  appa^ 
ratus  been  invented,  as  for  that  of  the  clavicle.  We  shall  ex- 
amine them  successively,  and  point  out  their  defeats  and  per- 
fections. The  ancients  and  many  of  the  moderns  have  ima- 
gined, that  in  order  to  set  a  fra<Slure  of  this  bone,  it  was  ne- 
cessary to  have  the  shoulder  drawn  back,  and  fixed  in  that 
position:  to  effect  this,  it  was  ordered  that  the  patient  should 
be  placed  on  a  low  stool,  so  that  an  assistant  might  place  his 
knee  between  his  shoulders,  which  he  drew  back  at  the  same 
time  with  both  his  hands,  whilst  the  surgeon  applied  the  band- 
age, which  was  to  keep  the  parts  in  this  position.  It  is  easy  to 
perceive  that  in  thus  drawing  the  shoulders  toward  one  ano- 
ther, the  scapula  is  pushed  toward  the  sternum,  and  with  it 
the  external  portion  of  the  clavicle,  which  passes  under  the  in- 
ternal. If  this  portion  be  sharp  pointed,  and  the  shoulders 
drawn  back  with  great  force,  it  may  lacerate  and  pierce  the 
integuments.  The  bandage  in  form  of  the  figure  8,  with 
which  it  is  attempted  to  keep  the  parts  in  this  position,  does 
not  corre£t  the  defedl  in  any  degree.  The  manner  of  its  ap- 
plication is  as  follows:  While  the  assistant  adts  as  above  men- 
tioned, the  operator  applies  one  end  of  a  seven  yard  bandage, 
rolled  up  in  one,  to  the  arm-pit  of  the  side  affected,  and 
draws  it  obliquely  to  the  opposite  shoulder,  round  which  it  is 
made  to  pass,  and  from  this  to  the  other  shoulder,  about 
which  it  is  to  be  rolled  in  the  same  manner,  and  crossed  after- 
wards repeatedly  before  and  behind.  As  this  bandage  a£ts  ob- 
liquely, its  force  is  decomposed;  it  is  therefore  necessary  to 
draw  it  very  tight,  in  order  to  keep  the  shoulders  back.  But 
this  extreme  constri(ftion  of  the  bandage  excoriates  the  parts 
about  the  arm-pits,  particularly  in  cases  of  women,  and  causes 
much  distress,  without  producing  any  good;  besides,  the 
drawing  back  of  the  scapulae  forces  the  fractured  portions  to 
overlap,  which  is  the  very  reverse  of  the  desired  effedl;  but 
luckily  the  obliquity  of  its  action  prevents  it  from  afting  so 
forcibly  as  to  confine  the  shoulders;  even  though,  as  prescri- 
bed by  J.  L.  Petit,  they  should  be  braced  behind  by  a  com-' 
press.  The  iron  cross  proposed  by  Heister,  the  corselet  de- 
scribed by  Brasdor  in  the  Memoirs  of  the  Academy,  and  the 
leather  strap  proposed  by  Brunninghaussen,  are  only  modifica- 


OF    FRACTURES   OF    THE    CLAVICLE.  75 

tions  of  the  figure  of  8  bandage,,  and  have  no  advantage  over 
it.  All  a£t  obliquely  on  the  shoulders,  tend  to  efFeft  a  de- 
rangement of  the  fraftured  portions,  by  drawing  the  scapulae 
toward  one  another,  excoriate  the  parts  about  the  arm-pits, 
and  do  not  prevent  the  descent  of  the  arm. 

The  general  rules  which  we  have  given  for  setting  fra^res, 
are  to  be  attended  to  in  those  of  the  clavicle.  Extension  is  to 
be  performed  by  means  of  the  limb,  which  articulates  with  the 
fraftured  bone,  and  in  the  direction  of  this  latter.  This  dou- 
ble purpose  is  answered  by  using  the  humerus  as  a  lever  of  the 
first  species,  that  is,  by  bringing  its  inferior  extremity  forward, 
inward,  and  upward,  and  pushing  the  shoulder  backward,  up- 
ward, and  outward:  the  humerus  may  be  converted  into  a  le- 
ver of  the  first  species,  by  placing  a  cushion  in  the  arm-pit, 
which  cushion  will  a£l  as  a  fulcrum  to  the  lever. 

The  Arabians,  and  Ambrose  Pare,  saw,  though  indistinftly, 
the  necessity  of  this  pra£lice,  and  now  and  then  had  recourse 
to  it;  but  it  remained  for  Desault  fully  to  d^velope  it,  and  in-? 
vent  an  appropriate  apparatus. 

The  practice  of  this  celebrated  surgeon  consisted  in  applying 
in  the  arm-pit  a  cushion,  made  of  hair  or  flocks,  five  or  six  inches 
long,  and  three  inches  and  a  quarter  thick  at  its  base.  To  the 
corners  of  its  base,  placed  upward,  are  fastened  two  strings, 
which  being  passed  across  the  back  and  breast,  are  to  be  tied 
on  the  opposite  shoulder.  The  cushion  being  thus  placed,  the 
surgeon  seizes  the  patient's  elbow,  the  fore-arm  being  bent, 
and  brings  it  forward,  upward,  and  inward,  pressing  it  with 
force  against  the  breast.  By  this  mancEuvre  the  humerus  car- 
ries the  shoulder  outward;  the  ends  of  the  fractured  portions 
are  placed  opposite  one  another,  and  the  deformity  disappears. 
All  that  is  then  necessary,  is  to  fix  the  arm  in  that  situation, 
and  prevent  it  from  moving  all  the  time  that  nature  requires 
for  the  consolidation  of  the  fracture.  For  this  purpose  an  as- 
sistant supports  the  arm  in  the  position  given  to  it  by  the  sur- 
geon; while  he  takes  a  bandage  nine  yards  long,  rolled  up  in 
one,  and  places  one  end  of  it  in  the  arm-pit  of  the  opposite 
side,  and  draws  it  from  thence  over  the  superior  part  of  the 
arm,  and  across  the  back  to  the  same  part.  This  first  cast  of 
the  bandage  is  exactly  covered  by  another,  which  secures  it, 
and  the  succeeding  casts  are  made  to  overlap  one  another  one 
third,  until  the  arm  is  covered  down  to  the  elbow;  taking  care 
at  the  same  time  to  draw  the  bandage  tighter  in  proportion  as 
it  descends;  because  the  bandage  must  be  considered  as  the 


76  OF    FRACTURES    OF    THE    CLAVICLE. 

force  which  aiEh  on  the  lever ;  for  which  reason  it  shoiuld  ope^ 
rat*  particularly  on  its  extremity. 

This  first  bandage  being  applied,  compresses  impregnated 
with  camphorated  spirit,  or  any  other  resolvent  fluid,  are  pla- 
ted along  the  fradlured  bone.  Then,  another  bandage  as  long 
as  the  former,  is  taken  by  the  operator,  and  one  end  of  it 
placed  under  the  arm-pit  of  the  opposite  side,  from  whence  it 
is  drawn  across  the  breast  over  the  compresses  and  the  fractur- 
ed part,  down  behind  the  shoulder  and  arm,  and  upward  on 
the  breast,  after  having  passed  under  the  elbow;  it  is  then 
brought  across  to  the  sound  shoulder,  under  and  round  which 
it  is  passed,  in  order  to  secure  the  first  cast;  it  is  then  drawn 
across  the  back,  brought  over  the  compresses,  carried  down 
before  the  shoulder  and  arm,  under  the  elbow,  and  obliquely 
behind  the  back  to  the  arm-pit,  where  the  application  com- 
menced. The  same  process  is  repeated  until  the  bandage  is 
entirely  applied.  The  principal  use  of  this  bandage  is  to  sup- 
port the  arm  5  it  admits  therefore  of  some  variety  in  its  appli- 
cation. By  means  of  these  two  bandages,  the  external  broken 
portion  is  raised  upward,  and  pushed  outward,  and  therefore 
tlie  two  principal  obje£ls  are  attained.  The  whole  apparatus 
may  be  still  further  fixed  and  secured,  by  pinning  the  bandage 
where  it  appears  to  have  any  effect.  Finally,  the  hand  is  to 
be  supported  by  means  of  a  sling. 

It  has  been  recommended  to  make  the  cushion  for  the  arm- 
pit of  old  linen,  but  hair  or  flocks  are  preferable  for  that  pur- 
pose. A  cushion  made  of  them  is  soft,  and  will  not  benumb 
the  arm  by  compressing  the  brachial  plexus,  or  occasion  an  in- 
flammation or  gangrene  of  the  parts. 

It  must  be  allowed  that  this  bandage  of  Desault  fulfils  every 
indication  of  cure;  but  it  has  a  disadvantage  necessarily  attend- 
ant en  every  such  bandage,  passed  by  a  great  number  of  casts 
round  a  part  so  bulky  as  the  trunk,  it  is  easily  deranged.  The 
dilatation  of  the  thorax  contributes  much  to  this  efi^eft,  parti- 
cularly in  women.  It  has  a  further  disadvantage  with  respedl 
to  females,  namely,  its  pressure  on  the  mammse,  which  must 
make  it  at  least  very  troublesome.  In  both  man  and  woman  it 
renders  respiration  difficult.  To  these  disadvantages  may  be 
added  that  arising  from  the  difliculty  of  applying  it,  on  ac- 
count of  the  number  of  pieces  of  which  it  consists,  and  the 
length  of  time  required  for  its  application.  Every  time  that  it 
becomes  deranged,  it  will  be  necessary,  in  order  to  re-apply  it. 


OF    FRACTURES    OF    THE    CLAVICLE.  77 

to  raise  the  arm  and  move  the  shoulder  more  or  less,  which 
motion  counteracts  the  consolidation  of  the  fracture. 

Convinced  by  his  own  experience,  of  these  disadvantages  of 
Desault's  apparatus.  Citizen  Boyer  has  invented  the  following 
one,  more  simple  and  less  troublesome;  by  means  of  which  he 
has  efFefted  a  complete  cure  of  a  fracture  of  the  clavicle, 
without  deformity. 

It  consists  of  a  girdle  of  linen  cloth,  quilted,  and  six  inches 
broad,  which  passes  round  the  trunk  on  a  level  with  the  elbow: 
it  is  fixed  on  by  means  of  three  straps,  and  as  many  buckles 
fastened  to  its  extremities.  At  an  equal  distance  from  its  ex- 
tremities are  placed  externally  on  each  side  two  buckles:  that  is, 
two  anterior  and  two  posterior  to  the  arm.  A  bracelet  of 
quilted  linen  cloth,  five  or  six  fingers  broad,  is  placed  on  the 
lower  part  of  the  arm  of  the  side  affected,  and  laced  on  the 
outside  of  the  arm;  four  straps  fixed  to  this  bracelet,  that  is, 
two  before  and  two  behind,  correspond  to  the  buckles  on  the 
outside  of  the  girdle,  already  described,  and  answer  the  pur- 
pose of  drawing  the  lower  part  of  the  arm  close  to  the  trunk; 
the  more  so  as  the  straps,  by  being  two  before  and  two  behind, 
prevent  the  arm  from  moving  either  backward  or  forward. 
With  this  apparatus,  as  well  as  with  the  preceding,  the  cushion 
must  be  applied  under  the  arm. 

Nothing  can  be  easier  than  the  treatment  of  a  simple  frac- 
ture by  means  of  this  apparatus,  the  use  and  application  of 
which  may  be  more  easily  conceived  by  the  assistance  of  the 
engraving  at  the  end  of  this  volume.  The  patient  himself  may 
tighten  the  straps  and  press  the  elbow  to  the  trunk,  whenever 
it  is  found  necessary.  He  may  quit  his  bed  in  a  few  days  and 
walk  about,  having  the  hand  and  fore-arm  supported  in  a  sling. 
A  fracture  of  the  clavicle  is  frequently  consolidated  in  thirty 
days,  during  which  time  the  patient  need  not  be  confined  to 
any  very  strict  regimen. 

These  fraiSlures,  when  compound,  are  treated  as  directed 
in  Chapter  I.  In  some  cases  it  may  be  necessary  to  rub  an  irri- 
tating substance  on  tlie  arm,  when  a  paralytic  affection  of  it  re- 
mains. If  the  fracture  be  double  or  comminutive,  it  will  be 
well  to  apply  a  flexible  splint  over  the  compresses  moistened 
with  a  resolvent  liquid,  as  already  directed. 

If  Desault's  bandage  be  employed,  it  will  be  necessary  to  re- 
new it  as  often  as  it  becomes  slack;  and  we  believe  that  its  hal- 
ving been  found  unsuccessful  by  several  practitioners,  is  to  be 
^scribed  to  the  negleCt  of  this  particular  circumstance. 


7» 


CHAPTER  X. 


OF  FRACTURES  OF  THE  HUMERUS. 

THIS  bone  may  be  fra£tured  in  any  point  of  its  length:  in 
the  middle,  at  either  extremity,  or  above  the  insertion  of 
the  pe(Storalis  major,  latissimus  dorsi,  and  teres  nnjor.  The  af- 
fection in  this  last-mentioned  case  is  termed  fradture  of  the  neck 
of  the  humerus  J  but  that  denomination  has  not  the  merit  of 
being  stridlly  anatomical.  It  is  possible,  however,  that  what 
is  striflly  called  the  neck  of  the  humerus  may  be  fradlured,  par- 
ticularly by  a  gun-shot  wound.  By  neck  of  the  humerus,  we 
understand  that  circular  narrowing  which  separates  the  tube- 
rosities from  the  head. 

The  fractures  of  this  bone  may  be  transverse  or  oblique,  sim- 
ple or  compound.  In  short,  whatever  has  been  said  of  the 
differences  of  fra£lures  in  general,  is  applicable  to  those  in  par- 
ticular. The  same  may  be  said  of  the  causes,  whether  acting 
on  the  extremities  of  the  bone,  or  immediately  on  the  part 
fractured. 

The  transverse  fractures  of  the  middle  part  under  the  inser- 
tion of  the  deltoid  muscle,  are  attended  with  but  a  trifling  de- 
rangement. The  anterior  bracliialis  and  triceps  brachialis,  at- 
tached posterioi'ly  and  anteriorly  to  both  fractured  portions, 
counteracfl  one  another,  and  admit  only  a  slight  angular  de- 
rangement. When  the  fracture  takes  place  above  the  insertion 
of  the  deltoid  muscle,  the  inferior  portion  is  first  drawn  out- 
ward, and  then  upward  on  the  external  side  of  the  superior. 
Fractures  of  the  humerus,  near  its  lower  end,  such  particularly 
as  are  transverse,  are  not  subject  to  much  derangement :  an  cf- 
fe£t  which  is  to  be  attributed  to  the  breadth  of  the  fractured  sur- 
faces; to  their  being  covered  posteriorly  by  the  triceps  brachi- 
alis, and  anteriorly  by  the  brachialis  anterior,  which  admit  only 
a  slight  angular  derangement  by  the  inferior  portion  being 
drawn  a  little  forward. 

The  oblique  fractures  are  always  attended  with  derangement, 
whatever  be   the  part  fractured.     The  inferior  portion  being 


OF    FRACTURES    OF    THE    HUMERUS.  79 

drawn  upward  by  the  action  of  the  deltoldes,  biceps,  coraco- 
brachialis,  and  long  portion  of  the  triceps,  glides  easily  on  the 
superior,  and  passes  above  its  lower  extremity.  Finally,  frac- 
tures of  the  neck  of  the  humerus  are  always  attended  with  de- 
rangement, which  is  produced  by  the  action  of  the  pe£loralis 
major,  latissimus  dorsi,  and  teres  major,  which  being  attached 
to  the  lower  portion  near  its  superior  extremity,  draw  it  first 
inward  and  then  upward,  in  which  last  direcliion  it  is  ix)werful- 
ly  aided  by  the  biceps,  coraco-brachialis,  and  long  portion  of 
the  triceps.  The  superior  portion  itself  is,  in  this  case  direfVed 
a  little  outward  by  the  action  of  the  Infraspinatus,  supraspinatus, 
and  teres  minor,  which  make  the  head  of  the  humerus  perform 
a  rotatory  motion  in  the  glenoidal  cavity. 

We  proceed  to  examine  the  different  marks  by  which  these 
fractures  may  be  ascertained. 

The  shortening  and  change  in  the  direction  of  the  limb,  the 
crepitation,  which  may  be  very  distinctly  perceived  by  moving 
the  broken  pieces  in  opposite  directions,  the  pain,  and  impos- 
sibility of  moving  the  arm,  &c.  joined  to  the  history  of  the 
preceding  circumstances,  render  it  easy  to  establish  a  diagnosis. 
It  may  happen  however,  from  ignorance  or  inattention,  that  a 
luxation  of  the  cubitus  may  be  mistaken  for  a  fracture  of  the 
lower  extremity  of  the  humerus.  In  treating  of  luxation,  we 
shall  state  how  this  mistake,  which  might  be  of  the  most  dan- 
gerous consequence,  may  be  avoided. 

Fraftures  of  the  neck  of  the  humerus  are  not  so  easily  ascer- 
tained, and  have  been  frequently,  for  want  of  attention,  con- 
founded with  luxations  of  that  bone.  The  diagnostic  symp^ 
toms  of  theses  two  affeftions  are  however  very  different. 

When  the  neck  of  the  humerus  is  fractured,  a  depression  is 
observed  at  the  superior  extremity  and  external  side  of  the  arm, 
which  is  very  different  from  that  accompanying  the  luxation 
downward  and  inward  of  that  bone,  in  the  latter  case,  under 
the  projeiStion  of  the  acromion,  a  deep  depression  is  found  ia 
the  part  which  the  head  of  the  humerus  naturally  occupies; 
whereas,  in  the  fracture  of  the  neck  of  that  bone,  the  shoulder 
retains  its  natural  form,  the  acromion  does  p.ot  project,  and 
the  depression  is  found  below  the  point  of  the  shoulder.  Be- 
sides, in  examining  the  arm-pit,  instead  of  finding  there  a  round 
tumour  formed  by  the  head  of  the  humerus,  the  fra<n:ured  and 
unequal  extremity  of  that  bone  will  be  easily  distinguished. 
The  motion  of  the  broken  portions,  and  the  crepitation  which 


86  OF    tRACTURES    OF    THE    HUMERUS. 

may  be  produced  by  moving  them,  serve  still  further  to  esta- 
blish the  diagnosis. 

A  simple  frafture  of  the^  body  of  the  humerus  is  not  a  very 
dangerous  afFedtion:  in  that  near  the  extremities,  the  danger 
is  greater,  because,  as  has  already  been  mentioned,  inflamma- 
tion and  false  anchylosis  are  more  to  be  apprehended,  and  the 
management  of  the  frafture  is  more  difficult. 

Transverse  or  oblique  fradlures  of  the  humerus  are  easily 
set.  An  assistant  placed  on  the  side  not  afFe<5led,  and  having 
his  hands  passed  before  and  behind  the  thorax,  fixes  the  shoul- 
der, while  another  draws  down  the  humerus,  by  seizing  the 
fore-arm,  or  even  the  condyloid  processes  of  the  humerus:  the 
operator  then  places  the  fradtured  surfaces  in  proper  contadl. 
The  criterion  of  the  frafture  being  well  set,  is  the  arm  having 
its  proper  length,  form  and  diredlion,  so  that  the  external  con- 
dyloid process  or  tuberosity  of  the  humerus  may  correspond 
with  the  most  salient  part  of  the  shoulder.  When  the  frac- 
ture is  thus  set,  the  surgeon  takes  a  bandage  eight  yards  long 
rolled  up  in  one,  and  having  placed  some  lint  in  the  palm  of 
the  hand,  commences  the  application  of  the  bandage  on  that 
part,  drawing  by  its  means  the  fingers  close  together,  after 
which  it  is  rolled  upward  on  the  rest  of  the  arm,  each  cast 
covering  a  part  of  the  preceding.  When  it  is  brought  as  far 
as  the  elbow,  the  fore-arm  is  to  be  bent;  and  when  carried 
as  high  as  the  depression  under  the  insertion  of  the  deltoides, 
some  lint  is  to  be  placed  under  it,  in  order  that  the  com- 
pression may  be  as  equal  as  possible;  the  whole  arm  is  to  be 
covered  alike;  but  three  folds  one  over  the  other,  are  to  be 
made  on  the  situation  of  the  fradlure.  When  the  bandage  has 
reached  the  shoulder,  four  thin  splints  of  wood,  or,  still 
better,  of  tin,  slightly  convex,  are  to  be  applied  one  oppo- 
site the  other  on  the  arm;  or,  if  the  arm  be  very  slender, 
three  splints  may  suffice.  While  an  assistant  holds  these  splints, 
they  are  fixed  by  turns  of  the  bandage  carried  downwards, 
which  cover  one  another  partially  as  before.  The  bandage  is 
brought  up  again  in  the  same  manner;  and,  if  long  enough, 
down  again  on  the  arm  and  fore-arm.  The  turns  of  the  band- 
age which  serve  to  fix  the  splints,  ought  not  to  be  drawn  so 
tight  as  to  cause  pain. 

It  is  indispensably  necessary  to  apply  the  bandage  on  the 
hand  and  fore-arm,  as  otherwise  these  parts  would  tumefy,  on 
account  of  the  circulation  in  the  veins  and  lymphatics  being 
©bstruded.     This  obstruftion,  though  not  very  painful,  is  at 


OF    FRACTlTRES    OF    THE    HUMERUS.  8l 

least  troublesome.  Besides,  the  articulation  is  rendered  stiff 
by  the  swelling,  and  the  stagnant  fluid  becoming  thick,  con- 
duces very  much  to  produce  a  false  anchylosis.  Should  this 
precaution  have  been  omitted  at  first,  the  bandage  should  be 
applied  even  after  the  swelling  has  taken  place.  It  is  scarcely 
necessary  to  say,  that  every  part  of  the  bandage  ought  to  be 
impregnated  with  some  resolvent  liquid:  independently  of  the 
repellent  effefts  of  the  liquid,  the  bandage  can  be  better  appli- 
ed when  wet  than  when  dry. 

If  the  patient  keep  his  bed,  a  pillow  should  be  placed  un- 
der the  arm;  on  the  contrary,  if  he  remain  up,  it  will  suffice 
to  support  the  hand  half  prone  in  a  sling.  If  the  patient  be 
very  vigorous,  it  will  be  prudent  to  draw  some  blood,  and  to 
put  him  on  a  very  low  diet  for  some  time.  If  no  bad  symp- 
tom come  on  after  the  application  of  the  apparatus,  it  need 
not  be  taken  ofl'  before  the  fifth  day,  and  afterwards  every 
eighth  or  tenth  day,  so  that  the  consolidation  will  be  found 
perfe(Sl  at  the  fourth  or  fifth  removal.  It  should  be  more  fre- 
quently re-applied  for  a  fracture  of  the  lower  extremity  of 
the  humerus.  The  articulations  of  the  elbow  and  shoulder 
should  be  frequently  moved,  in  order  to  prevent  a  false  anchy- 
losis;  but  the  motion  should  not  be  attempted  before  the  callus 
has  acquired  a  certain  degree  of  solidity. 

If  the  fradlure  be  complicated  with  violent  contusion,  and 
great  inflammation  be  inevitable,  or  already  established',  the 
limb  should  be  placed  on  a  pillow,  the  fore-arm  half  bent,  the 
hand  prone,  and  a  little  raised,  in  order  to  facilitate  the  circu- 
lation in  the  veins  and  lymphatics.  Scultet's  bandage  is  first 
applied,  its  separate  pieces  being  previously  extended  on  a 
linen  cloth  as  long  as  the  humerus;  the  splints  are  rolled  in 
this  cloth,  and  applied  over  the  bandage,  care  being  taken  to 
place  little  chaff  bags  where  they  may  be  necessary,  as  before 
dire£led.  The  strings  or  tapes  with  which  the  whole  is  to  be 
bound  externally,  should  not  be  drawn  too  tight.  It  will  be 
necessary  to  apply  emollient  poultices  on  the  arm,  when  the 
resolvent  applications  do  not  discuss  the  swelling.  By  accom- 
panying these  means  with  the  general  treatment  in  similar  ca- 
ses, such  as  bleedings,  rigorous  abstinence,  diluent  and  cool- 
ing drinks,  the  inflammatory  symptoms  disappear  in  seven  or 
eight  days,  and  the  rolled  bandage,  as  last  described,  may  be 
substituted  for  that  of  Scultet.  If  the  fra£ture  be  comminu- 
tive,  or  complicated  with  wound,  the  treatment  will  vary  as 
directed  in  Chapter  I.  on  the  General  Treatment  of  Fra(ftures. 
U 


S2  OF    FRACTURES    OF    THE    HUMERUS. 

It  has  been  advised  in  fractures  of  the  lower  extremity  of 
the  humerus,  to  place  the  four  splints  in  such  a  manner  as  that 
they  should  extend  equally  on  the  arm  and  fore-arm,  care  be- 
ing taken  to  equallize  the  anterior  and  posterior  sides,  particu- 
larly the  bend  of  the  arm  and  olecranon,  with  the  rest  of  the 
limb,  by  means  of  graduated  compresses  properly  disposed. — 
But  this  extension  of  the  whole  member  would  be  painful,  and 
might  produce  a  false  anchylosis  of  the  elbmv. 

If  the  case  require  it,  four  splints  may  be  so  hinged  in  their 
middle  part,  as  that  the  anterior  and  posterior  ones  should 
open  or  close  up  on  their  breadth,  and  the  two  lateral  ones  on 
their  edges.  Instead  of  these  hinged  splints,  Citizen  Boyer 
has  successfully  employed  four  simple  splints  for  the  humerus, 
and  four  more  for  the  fore-arm. 

The  fra£lure  of  the  neck  of  the  humerus  requires  a  mode  of 
treatment  which  it  is  necessary  to  particularize.  It  has  been 
proposed  in  this  ease  to  apply  the  spica,  or  the  eighteen  tailed 
bandage,  and  other  means  equally  insufficient.  Moscati,  a 
surgeon  of  Milan,  sensible  of  the  difficulty  of  ailing  in  these 
cases,  on  the  superior  portion,  invented  a  means  by  which  this 
inconvenience  was  overcome.  This  consisted  in  filling  the 
arm-pit,  previously  covered  with  a  cloth  fastened  on  the  out- 
side of  the  shoulder  with  tow  soaked  in  a  mixture  of  alum  and 
the  white  of  an  egg  beat  up  together.  He  covered  the  shoul- 
der with  a  similar  preparation,  and  over  that  applied  the  spica 
bandage.  This  mixture  dried  up  rapidly,  and  formed  a  hard 
crust  x-ound  the  part.  Thi^s  mode  of  treatment  (described  by 
the  author  in  the  Memoirs  of  the  Academy  of  Surgery)  has  a 
great  disadvantage;  it  forces  the  patient  to  keep  his  arm  at  a 
distance  from  the  trunk;  and  this  strained  and  unnatural  po- 
sition is  incompatible  with  the  exact  juxta-position  of  the  bro- 
ken portions,  the  situation  of  which  cannot  be  known  while 
covered  bv  this  substance. 

Ledran  thought  of  combining  this  invention  of  Moscati's 
with  the  means  used  by  the  ancients,  which  consisted  in  ma- 
king the  trunk  serve  as  an  internal  splint,  and  binding  the  arna 
to  the  trunk  by  a  circular  bandage.  This  correction  by  I.e- 
dran  led  to  the  invention  of  the  bandage  for  the  clavicle,  the 
application  of  which  Desault  extended  to  fractures  of  the  neck 
of  the  humerus.  According  to  this  method,  the  arm  is  en- 
veloped by  a  bandage,  and  the  elbow  pressed  toward  the 
breast,  a  cushion  being  first  placed  in  the  arm-pit:  another 
ciixuJar  bandage  is  then  passed  round  the  arm  and  trunks 


OF    FRACTURES   OF    THE    FORE-ARM.'  8j 

splints  are  applied  to  the  anterior,  posterior,  and  lateral  parts 
of  the  arm,  and  some  compresses  wet  with  a  resolvent  liquid 
are  applied  on  the  shoulder. 

By  means  of  this  apparatus,  fradhires  of  the  neck  of  the 
humerus  consolidate  as  easily,  and  sometimes  in  less  time  than 
those  of  its  middle  part. 

It  sometimes  happens,  that  in  young  subjects  the  head  of 
the  humerus,  being  yet  but  an  epiphysis,  separates  from  the 
rest  of  the  bone  in  consequence  of  a  blow  or  fall;  which  af- 
fedlion,  both  as  to  the  diagnostic  symptoms  and  treatment,  is 
analogous  to  a  frafture  of  the  same  part  in  a  more  advanced 
age.  It  is,  however,  particularly  necessary  in  this  case,  to  fill 
the  arm-pit  so  as  to  throw  outward  the  lower  portion  of  bone ; 
because,  if  the  parts  be  not  exadily  and  fairly  united,  the  mo- 
tions of  the  arm  will  be  impeded  to  a  certain  degree  for  ever 
after. 

In  compound  fractures  of  the  n^ck  of  the  humerus,  as  well 
as  in  those  of  the  body  of  that  bone,  no  attempt  is  to  be  made 
to  set  the  fracture  till  the  inflammatory  symptoms  have  subsi- 
ded. 


CHAPTER  XL 


OF  FRACTURES  OF  THE  FORE-ARM. 

SOME  authors  have  denominated  complete,  those  fraftures 
of  the  fore-arm  in  which  both  bones  are  fractured :  and 
incomplete,  those  in  which  one  only  is  frailured.  We  have 
already  given  it  as  our  opinion  that  these  denominations  are 
fallacious,  and  we  will  substitute  for  them  that  of  frafture  of 
the  fore-arm,  when  both  the  bones  of  which  it  is  composed 
are  fractured;  and  that  of  the  radius  or  cubitus,  where  only 
cne  of  these  bones  is  fractured. 


84  or   FRACTURES    OF    THE    FORE-ARM. 


SECTION    I. 


Of  FraElures  of  the  Fore-arm. 

They  are  almost  always  the  consequence  of  a  fall,  or  blow 
on  the  fore-arm,  and  take  place  in  the  part  on  which  the  cause 
has  immediately  adied.  It  is  difficult  to  imagine,  that,  by  a 
fall  on  the  palm  of  the  hand,  both  bones  could  be  fractured  at 
once,  because  the  radius  alone  receives  the  impulse  communi- 
cated by  the  hand:  the  cubitus  having  no  immediate  connexi- 
on with  the  hand,  cannot  be  often  fra£l:ured  by  this  cause. 

These  bones  may  be  fra(Slured  on  the  same  level,  as  most 
frequently  happens,  or  the  fracture  of  one  may  be  higher  than 
that  of  the  other.  Fradlures  of  these  bones,  whether  trans- 
verse or  oblique,  are  generally  complicated  with  greater  or  less 
contusion,  wound,  detached  splinters,  and  other  concomitants 
of  affections  of  this  kind. 

The  connexion  of  the  two  bones  of  the  fore-arm,  by  the  inr 
terosseous  ligament  which  occupies  the  interval  by  which  they 
are  separated,  and  the  manner  in  which  the  muscles  which  are 
attached  to  both,  are  inserted  into  them,  render  the  derange- 
ment of  the  broken  pieces  in  the  longitudinal  dire£iion  very 
difficulty  and,  in  reality,  a  derangement  in  this  dire(rtion  has 
been  seldom  observed,  and  never  to  any  considerable  degree: 
when  it  does  take  place,  it  is  to  be  ascribed  to  the  cause  of  the 
frafture  rather  than  to  muscular  contraction.  The  derange- 
ment in  the  dire<ftion  of  the  diameter,  on  the  contrary,  always 
takes  place  in  such  a  manner  as  that  the  four  pieces  approach 
one  another,  and  the  interosseous  interval  diminishes,  or  is  en- 
tirely obliterated  at  that  part  near  the  seat  of  the  fracture; 
which  approximation  of  the  ends  of  the  bones  causes  an  evi- 
dent deformity  of  the  part. 

To  this  derangement  must  be  added  the  angular,  which  the 
fracturing  cause  always  produces,  either  forward  or  backward, 
according  to  its  direCiion. 

The  existence  of  these  fraClures  is  easily  ascertained  from, 
the  history  of  the  circumstance,  from  the  pain,  which  is  ren- 
dered more  acute  by  moving  the  hand,  from  the  impossibility 
of  performing  pronation  or  supination  of  the  hand,  and  from 
the  noise  produced  by  the  fridlion  of  the  fractured  surfaces 


OF    FRACTURES    OF    THE    FORE-ARM.  85 

whenever  these  motions  are  attempted;  finally,  from  the 
change  in  the  form  of  the  arm,  the  anterior  and  posterior  sides 
of  which  appear  tumefied  by  the  protusion  of  the  muscles 
which  the  broken  bones  have  displaced  from  the  interosseous 
interval,  the  other  sides  being  depressed,  and  from  the  mobi- 
lity of  the  broken  portions,  and  change  in  the  dire(5lion  of  the 
arm. 

When  these  bones  are  fraftured  near  their  inferior  extremi- 
ties, the  inflammatory  swelling  might  render  a  diagnosis  less 
clear,  and  cause  the  fratSlure  to  be  mistaken  for  a  luxation  of 
the  hand.  But  the  two  cases  may  be  distinguished  by  simply 
moving  the  hand;  by  which  motion,  if  there  be  luxation  with- 
out fraclure,  the  styloid  processes  of  the  radius  and  cubitus 
will  not  change  their  situation;  but  if  a  fradlure  do  exist, 
these  processes  will  follow  the  motion  of  the  hand. 

In  order  to  adjust  a  fracture  of  these  bones,  the  fore-arm  is 
bent  to  a  right  angle  with  the  arm,  and  the  hand  placed  in  a  po- 
sition between  pronation  and  supination.  The  fore-arm  and 
hand  being  thus  placed,  an  assistant  seizes  the  four  fingers  of 
the  patient,  and,  by  pulling,  extends  the  fractured  parts,  while 
another  assistant  makes  counter  extension  by  fixing  the  hume- 
rus with  both  his  hands.  By  these  means  the  operator  is  ena- 
bled to  restore  the  bones  to  their  natural  situation,  and  to  push 
the  soft  parts  into  the  interosseous  space,  by  a  gentle  and  gra- 
duated pressure  on  the  anterior  and  posterior  sides  of  the  arm. 
Coaptation  is  very  easy  in  fra£lures  of  these  bones,  as  are  in- 
deed all  the  other  parts  of  the  operation,  in  which  effort  and 
violence  are  net  at  all  required. 

The  fradture  being  thus  set,  the  bones  are  kept  in  their 
place  by  applying  first  on  the  anterior  and  posterior  sides  of 
the  fore-arm  two  longitudinal  and  graduated  compresses,  the 
base  of  which  is  to  be  in  contact  with  the  arm.  The  depth 
of  these  compresses  should  be  proportioned  to  the  thickness 
of  the  arm,  increasing  as  the  diameter  of  the  arm  diminishes. 
In  the  next  place,  the  surgeon  takes  a  bandage  about  six  yards 
long,  rolled  up  in  one,  and  makes  three  turns  of  it  on  the 
fradtured  part,  descends  then  to  the  hand  by  casts  partially  su- 
perposed on  one  another,  and  envelopes  the  hand  in  passing 
the  bandage  between  the  thumb  and  index:  the  bandage  is 
then  carried  upward  in  the  same  manner,  and  reverted  where- 
ver the  inequality  of  the  arm  may  render  it  necessary.  The 
compresses  and  bandage  being  thus  far  applied,  the  surgeon 
lays  on  two  splints,  one  anteriorly,  the  other  posteriorly,  and 


S6  OF    FRACTURES    OF    THE    FORE-ARM. 

passes  the  part  of  the  bandage  that  yet  remains  over  them,  In 
such  a  manner  as  entirely  to  cover  them.  It  may  not  be  unne- 
cessary to  remark,  that  the  compresses  and  splints  should  be 
of  the  same  length  as  the  arm.  It  would  be  useless  to  employ 
lateral  splints  in  this  case,  unless  (what  is  scarcely  ever  to  be 
expe«n:ed  or  met  with)  a  derangement  should  have  taken  place 
in  that  direction.  It  is  evident,  that  lateral  splints  would  coun- 
teract the  compresses  and  two  other  splints,  by  increasing  the 
radio-cubital  diameter  of  the  arm,  and  by  concurring  with  the 
a<flion  of  the  pronatores  to  move  the  pieces  into  the  interosse- 
ous space.  The  surgeon's  attention  should  be  most  particular- 
ly dire^ed  to  preserve  the  interosseous  space;  for,  if  this  be 
obliterated,  the  radius  cannot  rotate  on  the  cubitus,  nor  the 
motion  of  pronation  or  supination  be  executed;  and  this  ob- 
je6l  may  be  obtained  with  certainty  by  applying  the  compresses 
and  splints  in  such  a  manner  as  that  the  fleshy  parts  may  be 
forced  into,  and  confined  in,  the  interosseous  space,  and  by 
renewing  the  bandage  every  seven  or  eight  days. 

Such  is  the  treatment  of  a  simple  fraclure  of  the  fore-arm; 
If  the  contusion  be  excessive,  with  wound  or  comminutive 
frafture,  the  splinters  should  be  extracted,  the  arm  placed  on 
a  pillow,  and  dressed  with  the  usual  topical  applications  adapt- 
ed to  the  degree  of  inflammation,  the  patient  bled,  and  Scul- 
tet's  bandage  applied.  If  the  inflammatory  symptoms  conthiue 
a  certain  length  of  time,  the  bones  consolidate  in  a  manner 
that  deforms  the  arm,  and  renders  it  impossible  to  perform  the 
movements  of  pronation  and  supination:  this  may  be  prevent- 
ed, if  the  inflammatory  symptoms  disappear  so  much  on  the 
fifteenth  or  twentieth  day  as  to  admit  the  application  of  the 
apparatus  for  simple  fractures. 

If  the  fraclure  be  simple,  and  the  contusion  inconsiderable, 
it  will  not  be  necessary  to  confine  the  patient  to  bed:  he  may 
be  allowed  to  walk  about  and  attend  to  his  business,  having 
the  arm  supported  in  a  sling.  The  consolidation  is  generally 
perfect  in  thirty  or  forty  days,  no  difference  being  perceivable 
in  the  time  necessary  for  the  generation  of  the  callus  in  the 
case  in  which  the  two  bones  are  fra<Slured,  and  that  in  which 
onlv  one  is  broken. 


OF    FRACTURES    OF    THE    RADIUS.  87 


SECTION    II. 


Of  Fracf lives  of  the  Radius. 

Of  all  fractures  of  the  fore-arm,  this  is  the  most  frequent; 
the  radius  being  almost  the  sole  support  of  the  hand,  of  which 
it  has  been  called  the  manubrium,  and  being  in  the  same  line 
with  the  humerus,  is  for  both  these  reasons  more  exposed  to 
frailure  than  the  cubitus,  which  corresponds  with  the  hand 
only  by  a  very  small  surface,  and  which  does  not  form  ^^ 
strait  line  with  the  humerus. 

Fradlures  of  this  bone,  v/hethcr  transverse  or  oblique,  rear 
its  middle  part  or  extremities,  may  be  caused  by  a  fall  or  blow- 
on  the  fore-arm,  or,  as  happens  in  most  cases,  by  a  fall  on  the 
palm  of  the  hand.  When  the  body  is  thrown  off  its  centre  of 
gravity,  and  falling  appears  inevitable,  we  are  apt  from  habit  to 
extend  our  arms,  and  let  the  hands  come  first  to  the  ground; 
in  which  case  the  radius,  pressed  between  the  hand  which  is 
supported  on  the  ground,  and  the  humerus,  from  which  it  re- 
ceives the  whole  momentum  of  the  body,  is  bent,  and  if  the 
fall  be  sufficiently  violent,  broken  more  or  less  near  its  middle 
part.  When  after  an  accident  of  this  kind,  pain  and  a  diffi- 
culty of  performing  the  motions  of  pronation  and  supination 
supervene,  the  probability  of  a  fradlure  of  the  radius  is  very 
strong.  The  truth  is  fully  ascertained  by  drawing  the  hand 
along  that*  bone  on  the  external  side  of  the  fore- arm,  with  as 
great  a  degree  of  pressure  as  the  pain  excited  will  admit :  be- 
sides, in  endeavouring  to  perform  supination  or  pronation  of 
the  hand,  a  crepitation  will  be  heard,  and  the  moving  of  the 
broken  portions  perceived,  if  the  bone  be  in  reality  fradlured  ; 
but  it  is  not  amiss  to  warn  against  mistaking  the  noise  made  by 
the  tendons  of  the  muscles  of  the  thumb  which  wind  on  the 
inferior  and  exterior  part  of  the  radius,  for  a  crepitation  pro- 
duced by  the  rubbing  of  the  fradlured  surfaces.  These  tendons 
are  thick  and  dry  in  labouring  people,  and  cause  a  certain  noise 
on  being  moved  in  their  sheaths,  in  which  there  is  a  scarcity 
of  synovia.  This  noise  is  easily  distinguished  from  crepitation 
by  an  experienced  ear.  When  the  fra<Si:ure  takes  place  near 
the  head  of  the  radius,  the  diagnosis  is  more  difficult  on  ac- 
count of  the  depth  of  soft  parts  over  the  bone  in  that  part.     In 


8B  OF    FRACTURES    OF*    THE    RADIUS. 

this  case  the  thumb  is  to  be  placed  under  the  external  condyle 
of  the  OS  humeri,  and  on  the  superior  extremity  of  the  radius, 
and  at  the  same  time  the  hand  is  to  be  brought  to  the  prone 
and  supine  positions.  If  in  these  trials,  always  painful,  the 
head  of  the  bone  rests  motionless,  there  can  be  no  doubt  of  its 
being  fractured.  The  causes  of  derangement  are  here  the  same 
as  in  fradtures  of  the  fore-arm,  and  it  can  never  take  place  but 
in  the  direftion  of  the  diameter  of  the  bone,  and  is  effected 
principally  by  the  action  of  the  pronating  muscles.  The  cubi- 
tus serves  as  a  splint  in  fradtures  of  the  radius-,  and  the  more 
effectually  so,  as  these  two  bones  are  conneiSled  with  one  ano- 
ther in  their  whole  length.  Notwithstanding  the  evidence  of 
the  mechanism  which  prevents  the  longitudinal  derangement, 
J.  L.  Petit  has  thought  that  derangement  possible. 

Extension  and  counter-extension  are  made  in  the  same  way 
as  in  fractures  of  both,  bones  of  the  fore  arm,  wltii  this  slight 
difference,  that  the  assistant  who  makes  the  extension  should 
incline  the  hand  to  the  cubital  side  of  the  fore- arm.  Great 
care  is  to  be  taken,  that,  by  means  of  graduated  compresses 
placed  on  the  anterior  and  posterior  sides  of  the  fore-arm,  the 
natural  shape  be  restored,  the  convexity  produced  by  the  frai?- 
ture  removed,  and  that  the  bandage  may  act  principally  on  the 
extremities  of  the  dorso  palmaris  diameters,  by  which  adtlon 
the  fleshy  parts  will  be  pressed  in  between  the  two  bones,  and 
therefore  these  bones  kept  separate,  and  the  Interosseous  space 
preserved  to  the  extent  which  is  natural,  and  Avhich  is  necessa- 
ry for  the  pronation  and  supination  of  the  hand. 

It  would  be  superfluous  to  repeat  here  what  has  been  said  in 
the  preceding  section  on  the  mode  of  perfecStlng  the  cure,  and 
combatting  the  symptoms  which  might  complicate  the  fracture: 
the  treatment  in  this  respedt  being  absolutely  the  same  in  both 
cases. 


SECTION    11.1. 


Of  FraHures  of  the  Cubitus. 

Fractures  of  this  bone,  less  frequent  than  those  of  the  radius 
for  the  reasons  already  mentioned,  take  place  generally  at  its 
lower  extremity,  because  it  is  smaller  and  less  covered  at  that  part 


i 


OF    FRACTURES    OF    THE    CUBITUS.  89 

than  at  any  other;  consequently  we  find,  that  a  frafVure  of 
this  bone  is  almost  always  the  result  of  a  force  a<Sting  immedi- 
ately on  the  part  fraclured;  as,  for  instance,  when  one  falls 
and  strikes  the  internal  side  of  the  fore-arm  against  a  hard  re- 
sisting body.  On  applying  the  hand  judiciously  on  the  inside 
of  the  fore-arm,  this  fradlure  is  easily  ascertained  by  the  de- 
pression in  that  part,  from  the  inferior  portion  being  drawn 
towards  the  radius  by  the  aclion  of  the  pronator  radii  quadratus. 
This  derangement  is  in  general  less  than  that  which  takes  place 
in  fractures  of  the  radius.  The  superior  portion  of  the  cubitus 
remains  unmoved,  as  has  been  well  observed  by  J.  L.  Petit. 

In  this  case  the  assistant  who  extends  the  parts,  inclines  the 
hand  to  the  radial  side  of  the  fore-arm,  the  surgeon  pushes  the 
flesh  between  the  two  bones,  and  applies  the  apparatus  last  de- 
scribed. In  all  fradlures '  of  the  bones  of  the  fore-arm,  and 
particularly  in  those  which  are  near  the  head  of  the  radius,  a 
false  anchylosis  is  to  be  apprehended,  and  should  be  guarded 
against  by  moving  the  elbow  gently  and  frequently,  when  the 
consolidation  is  advanced  to  a  certain  degree.  This  precaution 
is  more  especially  necessary  in  fractures  of  the  olecranon. 


SECTION   IV. 


Of  FraEiiires  of  the  Olecranon. 

This  curved  process,  by  which  the  cubitus  is  terminated  su- 
periorly, its  anterior  surface  being  covered  with  cartilage,  and 
its  posterior  having  the  tendon  of  the  triceps  brachialis  inserted 
into  it,  is  very  analogous  to  the  patella*,  and  the  resemblance 
would  be  perfect,  if  the  latter,  instead  of  being  attached  to 
the  tibia  by  a  strong  ligament,  were  a  continuation  of  its  sub- 
Stance,  as  the  olecranon  is  of  that  of  the  cubitus.  This  simili- 
tude is  still  stronger  in  the  fradlures  of  these  two  bones;  so  that 
what  will  be  said  on  fraftures  of  the  patella,  to  which  a  long 
chapter  shall  be  consigned,  may  be  applied  to  those  of  the  ole- 
cranon. 

These  last-mentioned,  which  almost  always  take  place  at  the 
base,  and  seldom  at  the  summit  of  the  olecranon  may  be  ob- 
lique, but  are  more  frequently  transverse.  They  are  occa- 
sioned sometimes  by  the  contraction  of  the  triceps  brachialis, 


90      OF  FRACTURES  OF  THE  OLECRANON. 

but  more  frequently  by  some  external  force,  as  by  a  fall  back- 
ward on  the  elbow.  The  fracture  of  the  patella  is,  on  the  con- 
trary, more  frequently  produced  by  muscular  contraction  than 
by  an  external  cause. 

When  the  olecranon  is  detached  from  the  cubitus  by  any 
cause,  it  is  always  drawn  upward  by  the  contradliun  of  the  tri- 
ceps brachialis,  and  the  interval  between  it  and  the  cubitus  is 
perceptible  to  the  touch  or  sight,  and  increases  or  diminishes  by 
the  fl(  Tcion  or  extension  of  the  fore-arm.  The  ascent  of  the  sepa- 
rated olecranon  along  the  lower  extremity  of  the  humerus,  may 
be  more  or  less  considerable:  in  all  cases  however,  it  ascends 
abo^-'i  the  condyles,  or  lower  tuberosities  of  the  humerus.  Fi- 
nall},  the  olecranon  may  be  pushed  by  the  fingers  to  one  side 
or  other,  without  any  motion  being  communicated  to  the  cu- 
bitus. 

Nothing  can  be  easier  than  to  distinguish  by  these  marks  a. 
fradlure  of  the  olecranon,  from  a  luxation  of  the  cubitus  back- 
ward, with  which,  however,  it  has  been  confounded.  It  is  true, 
that  v;hen  the  fraClure  has  been  occasioned  by  an  extremely 
violent  cause,  the  contusion  and  inflammatory  swelling  may 
be  so  great  as  to  render  the  diagnosis  difficult,  if  not  impossi- 
ble. But  this  uncertainty  should  not  influence  the  treatment, 
which  must  be  diredled  first  against  the  inflammation,  whether 
the  fracture  exist  or  not.  When  the  inflammation  and  its  con- 
comitant symptoms  have  been  allayed  by  blood-letting,  the  use 
of  emollients  and  other  such  means,  the  discovery  of  the  frac- 
ture will  be  easyj  and  if  it  be  found  to  exist,  it  is  to  be  treated 
in  the  following  manner. 

The  divided  parts  are  brought  into  contadl,  by  extending  the 
fore-arm,  and  pushing  down  the  olecranon  from  the  place  to 
which  it  had  been  drawn  by  the  contradlion  of  the  triceps. 
The  principal  objecl  is  to  counteract  the  action  of  this  muscle, 
which  tends  incessantly  to  separate  the  detached  olecranon  from 
the  cubitus.  To  efFeCl  this  purpose,  a  circular  bandage,  mode- 
rately broad,  is  passed  on  the  fore  arm,  fully  extended;  this 
being  done  the  olecranon  is  pushed  down  into  contact  with  the 
cubitus,  and  the  middle  part  of  a  long  compress  placed  behind 
it,  the  extremities  of  which  are  brought  downward  and  cros- 
sed on  the  anterior  part  of  the  fore-arm;  after  which  several 
turns  of  the  bandage  made  so  as  to  cross  one  another,  are  car- 
ried round  the  articulation  of  the  elbow.  The  bandage  should 
then  be  rolled  up  on  the  humerus,  in  order  to  diminish,  by 
pressure,  the  irritability  of  the  triceps  brachialis,  which  is  re- 


OF    FRACTURES   OF    THE    OLECRANONT.  9! 

laxed  by  the  extension  of  the  fore-arm.  This  bandage  being 
applied,  the  bend  of  the  fore-arm  is  filled  with  lint,  and  a  long 
splint  applied  on  it  anteriorly,  by  which  the  flexion  of  the  arm 
is  prevented.  This  splint  is  fixed  by  the  same  bandage,  rolled 
on  downward  from  the  shoulder  to  the  wrist,  and  upward 
again  if  the  bandage  be  long  enough.  The  oblique  casts  of 
the  bandage,  which  cross  one  another  on  the  articulation,  form- 
ing a  kind  of  a  figure  of  8,  ought  to  be  nicely  applied,  and 
drawn  very  tight  j  because  if  but  slightly  braced,  their  aflion, 
which  is  oblique,  will  not  be  sufficient  to  confine  the  olecranon 
to  its  situation.  Previous  to  the  application  of  these  oblique 
casts,  the  skin  of  the  olecranon  should  be  drawn  up  by  an  as- 
sistant; for,  if  this  precaution  be  not  taken,  it  may  sink  be- 
tween the  divided  portions  and  prevent  their  conta£l. 

Though  the  contact  be  exaft  immediately  after  the  applica- 
tion of  the  bandage,  yet  if,  as  is  apt  to  happen,  the  bandage 
become  relaxed,  or  if  the  patient  inadvertently  contract  the 
triceps,  the  olecranon  ascends,  because  the  bandage,  adting  per- 
pendicularly to  its  direction,  can  but  feebly  oppose  the  ascent 
of  this  process.  An  interval  will  therefore  exist  between  the 
cubitus  and  olecranon,  which  will  be  filled  up  by  granulations, 
and  by  the  thickening  of  the  periosteum,  or  tendinous  expan- 
sion of  the  triceps  which  covers  that  bone;  and  the  reunion  of 
the  parts  will  be  effected  by  means  of  an  intermediate  ligamen- 
tous substance,  the  length  of  which  will  depend  on  the  careful 
application  and  frequent  renewal  of  the  bandage. 

To  this  cause  as  Camper  supposed,  is  to  be  attributed  the 
Impossibility  of  obtaining  an  immediate  reunion  of  the  olecra- 
non to  the  cubitus,  and  not  to  a  defect  of  periosteum,  or  hu- 
meftation  of  the  parts  by  synovia,  as  some  authors  have 
thought. 

We  state  the  grounds  of  our  opinion  on  this  subje(5t  in  treat- 
ing of  fra<Stures  of  the  neck  of  the  humerus,  and  of  the  parella. 
In  forty  or  forty-five  days  the  ligamentous  substance  acquires 
its  greatest  consistence,  but  the  articulation  should  not  be  kept 
motionless  so  long;  gentle  motion  may  be  commenced  on  the 
twenty-fifty  or.  thirtieth  day.  The  object  of  these  motions  is  to 
prevent  a  false  anchylosis  of  the  articulation,  not,  as  David 
thought  by  preventing  the  growth  of  inequalities  or  asperities 
on  the  callus  but  by  facilitating  the  absorption  of  the  inspissa- 
ted fluids  accumulated  about  the  part ;  by  stimulating  the  secre- 
tion of  synovia,  and  exciting  the  irritability  of  the  muscles, 
benumbed  by  long  ina(Sl:ivity. 


92      OF  FRACTURKS  OF  THE  OLECRANON. 

In  cases  of  recovery  obtained  by  these  means,  the  olecranon 
adheres  to  the  cubitus  firmly  enough  to  transmit  to  it  the  ac- 
tion of  the  triceps  muscle,  and  to  moderate  the  extension  of 
the  fore-arm. 

Compound  fra(rture  of  the  olecranon  is  an  accident  of  the 
most  grievous  nature  on  account  of  the  great  number  of  nerves 
which  pass  in  the  neighbourhood  of  that  part ;  it  should  there- 
fore be  treated  with  the  greatest  care :  the  inflammatory  symp- 
toms are  to  be  combated  by  copious  and  repeated  bleedings  i 
the  arm  is  to  be  placed  half  bent  on  a  pillow,  and  dressed  with 
Scultet's  bandage.  In  these  cases  the  intermediate  ligamentous 
substance  is  always  longer  than  in  simple  fracture,  and,  conse- 
quently, the  force  of  the  arm  is  much  diminished.  If  a  false 
anchylosis  be  prevented  by  judiciously  exercising  the  articula- 
tion as  soon  as  the  state  of  the  parts  will  permit,  the  patient 
may  think  himself  fortunate. 

If  the  inflammatory  swelling,  &c.  be  not  dissipated  before 
the  twenty-fifth  or  twenty-sixth  day,  the  application  of  the  ap- 
paratus we  have  described  will  be  useless,  because  it  will  be  ne- 
cessary, at  that  time,  to  begin  to  exercise  the  articulation,  the 
formation  of  the  ligamentous  substance  being  then  considerably 
advanced. 


n 


CHAPTER  XII. 


OF  FRACTURES  OF  THE  BONES  OF  THE  HAND. 


SECTION   I. 


Of  FraBm'es  of  the  Bones  of  the  Carpus. 

THE  eight  small  bones  which,  placed  in  two  rows,  com- 
pose this  part  of  the  hand,  are  susceptible  only  of  com- 
miautive  fracture.  Their  smallness,  and  spongy  texture,  do 
not  admit  of  their  being  fractured  but  by  a  cause  which  a£ts 
on  them  immediately;  and,  in  fadt,  fractures  of  them  are  al- 
ways occasioned  either  by  a  gun-shot  wound,  or  some  very 
heavy  body  falling  on  the  hand.  It  is  obvious  that  in  cases  of 
this  nature,  more  attention  is  to  be  paid  to  the  state  of  the 
soft  parts  than  to  the  fra(Sture.  It  often  happens,  that  fractures 
of  these  bones  render  amputation  at  the  articulation  of  the 
wrist  necessary,  or  even  that  of  the  fore-arm. 


SECTION    II. 


Of  Fraclures  of  the  Bones  of  the  Aletacarpus. 

Fractures  of  these  bones  are  rare,  because  any  impulse  re- 
ceived by  the  hand  is  divided  between  all  these  bones.  That 
which  supports  the  thumb,  and  which  is  imconnected  with  the 
others,  Avould  be  frequently  fractured,  if  its  mobility  did  not 
secure  it  against  that  accident. 

These  fractures  are  always  the  result  of  a  force  immediately 
applied i  for  the  length  of  the  metacarpal  bones,  though  ranged 


94-       FRACTURES  OF  THE  METACARPUS. 

in  the  class  of  long  bones,  so  little  exceeds  their  other  dimen- 
sions, that  It  can  never  happen  that  a  force  acling  on  their  ex- 
tremities can  break  them  about  their  middle  part.  If  the  hand 
be  very  forcibly  pressed  between  two  bodies,  or  if  a  heavy  bo- 
dy fall  on  it,  commlnutlve  fracture  will  be  the  result;  and  al- 
most always  several  of  these  bones  are  fractured  at  once.  The 
following  case,  however,  furnishes  an  example  of  a  fraflure  of 
one  of  them.  An  armourer  proving  some  muskets,  made  use 
of  an  iron  ram-rod  for  setting  fire  to  the  priming:  the  musket 
was  forced  back  by  the  explosion,  and  the  iron  rod  thrust  into 
his  hand,  so  as  to  projcft  on  the  other  side,  and  raise  up  the 
integuments.  The  rod  was  drawn  out,  and  the  wound  dressed 
with  lint  and  emollient  poultices;  and  on  the  fourth  day  the 
patient  complained  of  excessive  pain,  when  he  attempted  to 
bend  the  fourth  or  ring  finger.  On  examining  the  part  with 
care,  and  pressing  the  fourth  bone  of  the  metacarpus,  it  was 
found  by  the  crepitation  and  motion,  that  that  bone  was  frac- 
tured. Two  long  compresses  were  applied,  one  to  the  palmi 
and  the  other  to  the  back  of  the  hand,  both  corresponding- 
to  the  fractured  bone:  over  these  were  placed  splinis,  which 
extended  to  the  extremity  of  the  finger.  A  bandage  was  then 
rolled  round  the  hand  and  three  last  fingers.  The  suffering  of 
the  patient  ceased  immediately  on  the  application  of  this  band- 
age, and  his  recovery  was  complete  in  six  weeks.  Comminu- 
tive  fradture  of  these  bones,  as  well  as  that  of  the  carpus,  fre-» 
quently  renders  amputation  necessary. 


SECTION    III. 


Of  F-raclurcs  of  the  Phalanges  of  the  Fingers. 

Fractures  of  these  bones  being  uniformly  the  effedl  of  the 
immediate  action  of  the  cause,  are  always  attended  with  more 
or  less  contusion.  The  alteration  in  the  form  of  the  finger, 
the  motion  of  the  broken  pieces,  and  the  crepitation  occasion- 
ed by  it,  leave  no  doubt  as  to  the  existence  of  the  frafturc. 

The  longitudinal  derangement  of  a  fractured  phalanx  is  ve- 
ry difficult;  and,  in  fa£l,  that  in  the  horizontal  direction  is 
almost  the  only  one  observed :  it  is  cfl'e(rted  by  the  lloxor 
tendons,  which  draw  the  inferior  portion  to  their  side.     The 


FRACTURES    07    THE    FINGERS,  95 

broken  pieces  may  be  brought  into  their  proper  situation,  by 
pulling  by  the  extremity  of  the  finger,  whilst  the  hand  is  fixed 
by  an  assistant.  A  circular  bandage,  moistened  with  a  solu- 
tion of  acetate  of  lead,  is  then  rolled  round  the  finger,  and 
over  that  are  placed  four  splints  of  thin  wood  or  pasteboard, 
which  are  fixed  on  by  the  same  bandage:  tlie  whole  dressing 
is  completed  by  including  the  two  adjacent  fingers  in  the  last 
turns  of  the  bandage. 

Fra<flures  of  these  bones  are  generally  united  in  twenty-five 
or  thirty  days,  but  the  finger  continues  a  little  stiff  for  about 
two  months,  at  the  end  of  which  time  the  stiffness  entirely 
Tanishes. 

When  a  very  heavy  body  has  crushed  the  extremities  of  the 
fingers,  or  when  they  have  been  bruised  by  a  folding  door,  the 
soft  parts  are  generally  lacerated,  the  nail  torn  off,  and  the  last 
phalanx  fra«Slured  and  denudated.  If  in  such  cases  the  parts 
hold  together  bya  shred  of  a-  certain  thickness,  'and  which  con- 
tains vessels  enough  for  the  nourishment  of  the  phalanx,  the 
reunion  of  the  parts  should  be  attempted.  The  prospect  of 
success,  it  is  true,  is  not  great  in  most  cases;  but  if  our  en- 
deavours to  save  the  finger  fail,  amputation  is  still  as  much  in 
our  power  as  in  the  commencement. 

If  the  last  phalanx  alone  is  crushed,  it  will  be  better  to  am- 
putate at  once,  than  attempt  to  save  the  joint.  The  cure  would 
be  tedious  and  difficult,  on  account  of  the  exfoliation  that 
would  take  place.  Besides,  the  part  being  deformed,  instead 
of  being  useful  would  be  troublesome.  By  amputating  at  the 
articulation  with  the  second  phalanx,  a  simple  wound  is  substi- 
tuted to  the  lacerated  and  ragged  wound  produced  by  the  cause 
of  the  fracture.  This  will  heal  in  a  very  short  time,  if  care 
be  taken  to  preserve  a  siifiiciency  of  skin  to  cover  the  sru-face 
of  the  articulation. 


96 


CHAPTER   XIII. 


OF  FRACTURES  OF  THE  THIGH. 

WHAT  has  been  said  of  the  treatment  of  fraclures  in 
general,  in  the  first  chapter  of  this  work,  is  more 
especially  applicable  to  those  of  this  bone  than  to  any  other. 
The  femur  is  much  exposed  to  fradlure  from  the  nature  of  its 
functions,  its  length  and  dire£lionj  and  notwithstanding  the 
great  depth  of  soft  parts  by  which  it  is  covered,  yet  it  is  fre- 
quently fractured. 

It  may  be  fra(Sl:ured  in  any  point  of  its  length,  near  the  mid- 
dle or  either  extremity.  We  shall  devote  a  particular  chapter 
to  fraftures  of  its  superior  extremity,  or  neck;  but,  besides 
these  last  mentioned,  there  is  another  species  of  fracSlure, 
which  consists  in  the  separation  of  the  great  trochanter  from 
the  body  of  the  femur.  In  the  fraftures  of  the  lower  extre- 
mity of  the  femur,  not  only  one  of  the  condyles  may  be  sepa- 
rated longitudinally  from  the  rest  of  the  bone,  but  both  con- 
dyles may,  at  the  same  time,  be  separated  one  from  the  other, 
and  from  the  rest  of  the  bone.  All  varieties  of  simple  or 
compound  fradbure  may  be  observed  in  those  of  the  femur. — 
They  may  be  produced  in  any  part  of  it  by  a  cause  adting  im- 
mediately on  that  part,  or  by  a  force  ailing  on  its  extremities, 
which  will  probably  produce  a  fracture  of  the  middle  part, 
where  the  bone  is  naturally  bent:  a  fradlure  produced  by  any 
of  these  causes,    may  be  transverse  or  oblique. 

Derangement  of  the  fraftured  portions  is  a  uniform  conco- 
mitant of  fradlures  of  the  thigh;  it  may  take  place  in  any  of 
the  four  direi^ions  already  repeatedly  mentioned,  but  that 
most  frequently  observed  is  the  longitudinal  derangement  by 
which  the  limb  is  shortened.  The  numerous  muscles  of  the 
thigh,  by  means  of  which  derangement  may  be  efFc6ted,  are 
divisible  into  three  classes,  relative  to  the  manner  in  which 
they  tend  or  contribute  to  effedt  it.  The  three  portions  of  the 
triceps  femoris  are  attached  to  both  pieces,  and  tend  to  produce 
the  angular  derangement  by  drawing  the  two  fractured  nor- 


OF    FRACTURES    OF   THE    THIGH.  57 

tions  to  a  salient  angle  on  the  outside,  where  their  fibres  are 
the  strongest  and  most  numerous.  The  biceps  femoris,  semi- 
tendinosus,  semimembranosus,  sartorius,  redlus  internus,  and 
third  addudlor,  all  those,  in  short,  which  extend  from  the  pel- 
vis to  the  inferior  portion,  or  to  the  leg  with  which  it  articu- 
lates, tend  to  draw  the  inferior  portion  upward,  on  the  internal 
side  of  the  superior,  the  extremity  of  which  forms  a  tumour 
on  the  external  side  of  the  thigh.  The  inferior  portion  is  that 
which  is  always  displaced,  except  when  the  fradture  takes  place 
immediately  under  the  small  trochanter,  to  which  pioce'i'^  are 
attached,  by  a  common  insertion,  the  psoas  and  illiacus  muscles; 
which  muscles  would,  in  such  a  case,  draw  the  superior  portion 
upward  and  forward,  producing  by  that  means  a  tumour  in 
the  groin. 

When  the  femur  is  fractured  immediately  above  the  con- 
dyles, the  inferior  piece  is  drawn  backv/ard,  and  its  superior 
surface  turned  downward  by  the  atftion  of  the  gastrocnemius 
externus,  plantaris,  and  popliteus  muscles.  When  the  great 
trochanter  is  detached  from  the  rest  of  the  bone,  it  is  drawn 
upward  by  the  muscles  which  are  inserted  into  it,  but  without 
producing  any  change  in  the  diredtion  or  form  of  the  thigh. 

The  angular  derangement  in  which  the  foot  inclines  either 
inward  or  outward,  is  the  effedt  of  the  weight  of  the  foot,  or 
of  the  bed  clothes,  rather  than  of  muscular  contra(5lion.  It 
shall  be  mentioned  more  particularly  in  treating  of  fractures  of 
the  neck  of  the  femur. 

Deformity  and  diminution  of  the  length  of  the  limb,  a 
change  in  its  dire6lion,  the  tumour  occasioned  by  the  deranged 
portions  of  the  broken  bone,  the  impossibility  of  performing  the 
ordinary  motions,  the  acute  pain  and  crepitation  produced  by 
the  motion  of  the  broken  pieces  one  on  the  other,  indicate  a 
fracture  of  the  femur  in  such  a  marked  manner,  that  it  is  im- 
possible to  mistake  it.  Fractures  of  the  thigh  are,  caterls  pari- 
busy  more  dangerous  than  those  of  any  other  of  our  limbs,  on 
account  of  the  difficulty  of  keeping  the  pieces  in  a  proper  si- 
tuation. The  ancients  considered  a  fracture  of  the  femur  dif- 
ficult to  be  cured  without  a  shorteniiag  of  the  limb;  but  at 
present  the  possibility  of  cure  without  any  change  or  deformi- 
ty is  attested  by  numerous  instances.  It  is  to  be  remarked, 
however,  that  nlore  unremitting  care  and  attention  is  necessa- 
ry in  fraiHiures  of  this  bone,  than  in  those  of  any  other. 
13 


9?  OF    FRACTURES    OF    THE    THIGH, 

We  shall  point  out,  at  some  length,  the  objecls  to  which 
the  attention  is  to  be  particularly  directed  in  the  treatment  of 
these  fraftures. 

The  bed  in  which  the  patient  is  to  lie  should  not  exceed 
three  feet  in  breadth;  a  broader  bed  would  render  the  raising 
and  re-application  of  the  apparatus  very  troublesome.  It  should 
have  no  foot-board,  otherwise  the  assistant,  whose  duty  it  is 
to  make  the  extension,  could  not  conveniently  draw  the  leg  in 
the  proper  diredlion.  Instead  of  a  bed  of  down  or  feathers,  a 
hair  mattress  should  be  used,  which  will  not  allow  the  limb,  the 
■weight  of  which  is  augmented  bv  the  apparatus,  to  sink.  If 
mattresses  of  wool  are  the  only  bedding  to  be  found,  their  so- 
lidity should  be  increased  by  placing  between  them  thin  elastic 
boards.  The  head  of  the  patient  should  repose  on  a  simple 
pillow,  the  horizontal  position  being  one  of  the  desiderata. 
When  the  head  is  too  much  raised  by  pillows,  &c.  the  body 
tends  to  descend,  and  deformity  of  the  limb  will  be  the  conse- 
quence, whatever  attention  may  be  paid  in  other  respefts. 

These  particulars  relative  to  the  bed  being  punftually  attend- 
ed to,  an  apparatus,  as  follows,  is  in  the  next  place  to  be  pre- 
pared: First,  as  many  bandages,  of  three  fingers  breadth  each, 
as  will  be  sufficient  to  cover  the  leg  and  thigh,  and  which  will 
form  what  has  been  already  described  under  the  name  of  Scul- 
tet's  bandage:  secondly,  a  number  of  long  compresses,  wet 
with  some  resolvent  liquid,  which  are  placed  on  such  parts  of 
the  limb  as  appear  most  inflamed:  thirdly,  a  splint-cloth,  or 
fanon^  in  which  the  two  lateral  splints  are  rolled:  the  splints 
should  be  long  enough  to  extend  externally,  from  the  ridge  of 
the  OS  ilium,  and  internally,  from  the  articulation  of  the  fe- 
mur to  a  few  inches  beyond  the  sole  of  the  foot ;  and  anteri- 
orly from  the  groin,  or  anterior  side  of  the  articulation  of  the 
femur  with  the  bones  of  the  pelvis,  to  the  instep:  fourthly,  three 
bags  of  chaff,  by  means  of  which  the  sides  of  the  thigh  may  be 
rendered  parallel  with  the  splints:  fifthly,  and  finally,  five  strings 
or  ribbands,  by  which  the  rest  of  the  apparatus  arc  to  be  secured 
externally:  two  are  to  be  placed  on  the  thigh,  two  on  the  leg, 
and  one  is  to  be  crossed  on  the  instep  and  sole  of  the  foot,  and 
its  ends  made  fast  to  the  internal  and  external  splints,  in  order 
to  prevent  the  vacillation  of  the  foot. 

Some  pra(Stiti oners  apply  Scultet's  bandage  on  the  thigh  only, 
and  do  not  extend  it  to  the  leg,  nor  envelope  the  foot  in  long 
compresses,  drawn  moderately  tight  j  in  consequence  of  which 
negledl,  the  leg  and  foot  are  apt  to  swell,  from  the  return  of 


©F    FRACTURES    OF    THE    THIGH.  ^A 

the  fluids  being  impeded  by  the  compression  of  the  bandage  on 
the  thigh. 

This  apparatus  should  be  extended  on  the  bed  on  which  the 
patient  is  to  be  laid,  in  the  order  of  their  application ;  that  is, 
first  the  strings  or  ribbands;  next  the  fauofi  or  splint-cloth;  and 
over  that  Scultet's  bandage,  of  which  the  different  parts  should 
partially  cover  one  another;  and  last  of  all,  the  compresses. 
The  patient,  if  dressed,  is  to  be  undressed  very  gently,  and 
the  fractured  limb  is  to  be  moved  as  little  as  possible.  In  con- 
veying the  patient  to  the  bed  on  which  he  is  to  lie  during  the 
treatment,  the  surgeon  himself  ought  to  support  the  fractured 
limb,  and  place  it  exactly  on  the  middle  of  the  apparatus.  The 
setting  is  in  the  next  place  to  be  proceeded  to;  to  effect  which, 
the  strongest  of  the  assistants  renders  the  pelvis  immoveable,  by 
pressing  on  the  anterior  and  superior  processes  of  the  ossa  ilia, 
whilst  another  assistant  seizes  the  foot  with  both  hands,  the 
thumbs  applied  to  the  sole,  and  the  fingers  crossed  on  the  up- 
per part,  and  draws  it  with  a  gradual  effort,  first  obliquely 
outward,  and  then  quickly  in  its  natural- direction :  the  surgeon 
placed  on  the  external  side,  performs  the  coaptation;  but  the 
great  depth  of  integuments  renders  this  part  of  the  operation 
almost  entirely  useless. 

The  natural  form  and  length  of  the  limb  being  restored,  the 
assistants  continue  the  extension  and  counter  extension,  while 
the  surgeon  applies  the  different  parts  of  the  apparatus  in  the 
order  already  described,  rolling  compresses  on  the  thigh  and  leg, 
and  commencing  the  application  of  Scultet's  bandage  from  the 
lower  extremity  of  the  leg,  and  proceeding  upward.  The  splints 
rolled  up  in  the  cloth,  are  placed  perpendicularly  on  their  edges, 
at  a  small  distance  from  the  leg,  in  which  interval  bags  of  chaff 
are  to  be  placed,  and,  on  the  chaff  being  pushed  into  the  dif- 
ferent depressions,  so  as  to  equalize  the  surface  of  the  limb,  and 
provide  for  the  equable  pressure  of  the  splints,  these  latter  are 
pressed  against  the  limb  by  the  hands  of  an  assistant,  while  the 
surgeon  ties  on  the  strings,  by  commencing  with  the  one  at  the 
middle  part  of  the  thigh.  The  fillet  crossed  on  the  foot,  and 
tied  to  the  extremities  of  the  lateral  splints,  is  the  last  apphed. 

It  may  be  necessary  to  bleed  the  patient  once  or  twice,  and  to 
confine  him  to  the  antiphlogistic  regimen  for  four  or  five  days, 
at  the  end  of  which  time  no  disagreeable  consequences  are  to  be 
apprehended.  If  the  pain  and  suffering  of  the  patient  be  not 
excessive,  the  apparatus  need  not  be  raised  for  the  first  three 
or  four  days,  but  this  measure  should  not  be  deferred  beyond 


lOO  OF    FRACTURES    OF    THE    THIGH. 

that  time;  fof,  however  well  the  fracture  may  have  been  set, 
and  however  well  and  permanently  the  apparatus  may  appear  to 
have  been  applied,  yet  it  is  possible  that  the  pieces  of  bone  may 
have  been  displaced  by  the  aftion  of  the  muscles.  By  neglect- 
ing this  precaution,  and  raising  the  apparatus  only  every  eight 
days,  the  fractured  portions  have  passed  one  another,  and  con- 
solidated in  that  situation,  and  a  lameness  has  been  produced, 
which  could  never  be  remedied.  At  the  end  of  about  forty-five 
days,  when,  after  having  reapplied  the  apparatus  eight  or  nine 
times,  the  callus  is  found  so  far  formed  as  to  bear  the  motion 
of  the  whole  member,  Scultet's  bandage  is  to  be  taken  off^ 
and  a  simple  roller  substituted  in  its  stead,  capable  of  compres- 
sing the  soft  parts,  and  of  preventing  the  oedematous  swelling 
likely  to  take  place. 

The  foregoing  mode  of  treating  fraftures  of  the  femur,  and 
which  is  efFecStual  when  they  are  transverse,  is  of  little  or  no 
efFeft  in  cases  of  oblique  fraclure,  which  was  supposed  by  the 
ancients  to  produce  necessarily  a  shortening  of  the  limb.  In 
order  to  prevent  this  continued  extension,  the  mechanism  of 
which  shall  be  explained  in  the  chapter  on  fra£lures  of  the  neck 
of  the  femur,  has  been  employed  by  the  moderns. 

If  a  very  young  child,  as  for  instance,  one  of  two  or  three 
years,  is  to  be  treated  for  a  fracture  of  the  thigh,  a  roller  of 
one  piece  may  be  employed  instead  of  Scultet's  bandage.  Four 
elastic  wooden  splints  should  be  applied  on  the  opposite  sides  of 
the  limb,  and  secured  by  the  circular  bandage,  a  part  of  which 
has  been  already  applied.  It  is  not  necessary,  in  this  case  that 
the  splints  should  be  longer  than  the  limb,  because  the  foot,  at 
that  age,  bears  a  less  proportion  to  the  rest  of  the  member,  than 
at  a  more  advanced  period,  and  is  not  weighty  enough  to  draw 
the  limb  to  either  side  with  it.  The  principal  reason  for  pre- 
ferring the  circular  bandage  in  the  case  of  children,  is  the  dif- 
ficulty of  re-applying  the  other  apparatus  every  day,  or  as  often 
as  it  maybe  soiled  by  the  urine  and  faces :  it  will  be  necessary, 
for  the  same  reason  to  roll  up  the  whole  limb,  after  the  appara- 
tus has  been  applied,  in  several  folds  of  a  strong  linen  cloth, 
which  should  be  renewed  every  day.  This  is  the  only  case  in 
which  Scultet's  bandage  is  not  to  be  preferred  to  any  other. 

When  the  femur  is  fradlured  near  the  condyles,  it  will  be 
necessary  to  stuff  the  hollow  of  the  ham  with  lint,  in  order  to 
prevent  the  lower  fractured  portion  from  being  drawn  back  by 
the  action  of  the  muscles  attached  to  It:  if  this  derangement  be 
not  guarded  against,  the  popliteal  nerves  and  vessels  may  be 


OF    FRACTURES    OF    THE    THIGH,  lOI 

wounded  by  the  protrusion  of  the  fraftured  end  of  the  bone, 
and  the  worst  consequences  may  ensue. 

If  the  great  trochanter  be  separated  from  the  rest  of  the 
bone,  the  middle  part  of  a  long  compress  is  to  be  applied  on 
that  process,  and  its  extremities  drawn  downward  and  inward ; 
over  which  compress  a  spica  bandage  for  the  groin  is  to  be  ap- 
plied. 

More  time  is  necessary  for  the  consolidation  of  fradlures  of 
the  femur,  than  for  those  of  any  other  long  bone,  on  account 
of  the  great  compadbiess  of  its  texture,  particularly  near  its 
middle  part.  For  this  reason  it  is  in  general  necessary  to  con- 
tinue the  apparatus  applied  for  fifty  days,  and  sometimes  for 
even  a  longer  time. 

If  the  consolidation  be  very  tedious,  a  stiffness  in  the  articu- 
lation of  the  knee  will  be  a  necessary  consequence;  and,  if  the 
fracture  be  so  near  the  condyles  as  that  the  swelling  and  ob- 
strudlion  may  extend  to  the  articulation,  this  consequence  vi'ill 
be  inevitable,  and  very  difficult  to  remove. 

It  would  be  superfluous  to  repeat  here,  respecting  compound 
fradtures  of  the  femur,  what  has  been  already  said  on  this  sub- 
ject in  the  first  chapter,  and  frequently  repeated  by  particular 
applications.  We  shall  therefore  without  further  delay,  pro- 
ceed to  consider  the  fradlures  of  the  neck  of  the  femur. 


102 


CHAPTER  XIV. 


OF  FRACTURES  OF  THE  NECK  OF  THE  FEMUR. 


THE  neck  of  the  femur  may  be  fractured  in  any  point  of 
its  extent.  The  fracture,  however,  most  frequently  takes 
place  in  its  middle  part,  and  more  generally  towards  or  at  its 
base,  than  at  its  union  Math  the  head  of  the  femur,  although 
its  base  is  its  thickest  part.  These  fractures  exist  stricStly  speak- 
ing, within  the  articulation;  the  orbicular  ligament  of  which 
adheres  to  the  lower  portion  of  the  bone,  the  superior  having 
no  connexion  with  the  rest  of  the  body,  but  by  the  round  liga- 
ment; except,  however,  the  case  in  which  the  ligament  re- 
flected round  the  neck  is  not  entirely  ruptured.  These  fractures 
are  almost  always  transverse;  the  reason  of  which  is  found  in 
the  spongy  texture  of  the  bone.  In  many  cases  the  surfaces  of 
the  divided  bone  are  very  unequal,  the  one  being  marked  with 
asperities  or  eminences,  and  the  other  with  corresponding  de- 
pressions. 

There  is  another  species  of  variety  of  this  fracture  which  takes 
place  outside  the  articulation,  near  the  union  of  the  bone  with 
its  trochanters,  and  sometimes  between  these  two  eminences, 
the  greater  of  which  adheres  then  to  the  superior  portion. 
There  have  been  so  many  instances  of  fractures  of  this  nature, 
that  all  are  now  agreed  as  to  the  possibility  of  their  taking 
place. 

A  member  of  the  ci-devant  Academy  of  Surgery  fell  on  the 
great  trochanter;  the  extremity  of  this  side  became  shorter 
than  that  of  the  opposite,  the  foot  and  the  knee  inclined  out- 
ward, and  in  short,  all  the  symptoms  of  frac^ture  of  the  neck  of 
the  femur  were  manifest,  and  the  existence  of  such  a  fracture 
was  agreed  on  by  a  number  of  his  brother  surgeons.  The  frac- 
ture was  treated  in  the  ordinary  way,  and  a  cure  was  obtained, 
but  not  without  a  shortness  of  the  limb.  This  person  died  short- 
ly after  from  another  disease;  his  body  was  opened,  and  the 


\ 


OF    FRACTURES    OF    THE    FEMUR.  lOJ 

articulation  of  the  thigh  examined,  when  it  was  found  that  the 
fracture  had  taken  place  below  the  insertion  of  the  orbicular  li- 
gament. I  am  indebted  for  this  case  to  Citizen  Lesne,  a  dis- 
tinguished member  of  the  Academy,  and  editor  of  the  Posthu- 
mous Works  of  J.  L.  Petit.  Citizen  Boyer  has  met  several  cases 
of  a  similar  kind. 

I  have  seen  a  remarkable  case  of  a  shortened  inferior  extre- 
mity, in  an  old  man,  who  died  in  the  hospital  of  La  Charitffy 
in  the  year  seven.  A  double  fradlure  was  found,  one  inside  and 
one  outside  the  orbicular  ligament;  the  latter  between  the  two 
trochanters,  the  larger  of  which  was  separated  from  the  rest  of 
the  bone.  Although  the  patient  was  eighty  three  years  of  age, 
yet  the  consolidation  had  commenced. 

Fradlure  of  the  neck  of  the  femur,  generally  simple,  is  some- 
times complicated  with  that  of  the  great  trochanter,  very  rarely 
with  contusion,  because  the  force  which  produces  it  does  not 
aft  immediately  on  the  part.  Protefted  by  a  great  depth  of 
soft  parts,  and  by  the  great  trochanter,  the  neck  of  the  femur 
is  seldom  fradlured  comminutively.  That  might  however  take 
place  from  a  gun-shot  wound;  but  as  in  that  case  the  bones  of 
the  pelvis  must  also  be  fractured,  and  the  parts  contained  in  it 
injured :  the  fradlure  of  the  neck  of  the  femur  is  but  the  slight- 
est part  of  the  affedlion. 

Amongst  the  various  fradlures  of  the  neck  of  the  femur  ought 
to  be  enumerated  the  decollation  of  the  epiphysis,  which, 
though  rare,  has  yet  been  observed.  Pare*  mentions  the  pos- 
sibility of  this  decollation,  allows  that  its  diagnosis  is  extremely 
obscure,  and  assures  us  at  the  same  time,  that  it  has  been  often 
mistaken  by  very  expert  surgeons  for  a  luxation.  Young  per- 
sons only  are  subjedl  to  this  accident,  because  it  cannot  take 
place  when  the  cartilage  which  unites  the  neck  to  the  bone  is 
ossified. 

The  superior  extremity  of  the  femur  is  entirely  cartilaginous 
in  the  new-born  infant;  but  soon  after  birth  three  points  of  ossi- 
fication maybe  observed  in  it,  one  corresponding  to  the  head  of 
that  bone,  and  the  two  others  to  the  trochanters.  These  osse- 
ous points  gradually  spread,  the  cartilage  diminishes,  and  at 
length  entirely  disappears;  but  the  ossification  of  the  head  and 
neck  is  much  slower  than  that  of  the  trochanters  ;  nor  does  the 
cartilage  of  these  parts  totally  disappear  before  the  eighteenth 
or  twentieth  year. 

*  Works  of  Ambrose  Pare,  lib.  15.  chap.  ai. 


104  OF    FRACTURES    OF    THE    FEMUR. 

It  is  easy  to  conceive  that  an  accident,  which  at  a  more  ad- 
vanced period  of  life  would  produce  fratfture  of  the  neck  of 
the  femur,  will  with  more  facility  separate  the  head  before  the 
age  of  eighteen  or  twenty.  It  may  even  happen  that  a  force 
"which  does  not  produce  this  decollation,  shall  however,  disjr- 
ganize  the  cotyloid  cavity,  by  impelling  inward  towards  the 
pelvis  the  parts  of  the  three  bones  of  which  that  cavity  is  com- 
posed. Ludwig*  has  given  a  case  of  this  kind.  When  the 
head  and  neck  of  the  femur  are  completely  united,  their  point 
of  union  is  seldom  the  situation  of  a  fra^hire;  and,  as  Duver- 
ney  remarks,  decollation  is  then  impossible! .  '^^^  symptoms  of 
decollation  differ  little  from  those  of  fra6lure:  the  dull  crepita- 
tion which  has  been  given  as  a  sign  by  J.  L.  Petit:]:,  is  by  his  own 
acknowledgement  very  equivocal.  But  this  difficulty  in  form- 
ing a  diagnosis  is  of  no  great  consequence,  as  the  treatment 
does  not  differ  from  that  of  fracture  of  the  neck  of  the  femur; 
nor  is  the  prognosis  more  unfavourable,  notwithstanding  what 
Columbus^,  arguing  from  the  difficulty  of  setting  the  divided 
portions  with  acuracy,  says  to  the  contrary. 

Predisposing  Causes. — Brittleness  of  the  bones,  as  well  as  the 
vices  of  the  constitution  on  which  it  depends,  has  been  already 
given  a«  a  predisposing  cause  of  fra(fture.  Caries  may  be  look- 
ed on  as  a  predisposing  cause  of  fra6lure  of  the  neck  of  the  fe- 
mur, by  its  destroying  a  part  of  the  substance  of  the  femur  j 
but  as  in  this  case  artificial  means  can  have  no  effect  in  produ- 
cing a  consolidation  of  the  fraflure,  and  as  the  caries  will  pro- 
bably occasion  the  patient's  death,  unless  nature  effedt  the  union 
of  the  carious  bone  with  some  part  of  the  pelvis,  it  seems  use- 
less to  give  any  further  consideration  to  fractures,  or  division  of 
the  neck  of  the  femur  from  this  cause.  Rickets,  which  some 
authors  have  mentioned  as  a  predisposing  cause  of  fradlure,  ra- 
ther prevents  it  by  rendering  the  bones  flexible. 

Duverney  has  given  a  case  of  a  fraclure  of  the  neck  of  the 
femur,  in  which  the  vcYiereal  disease  was  evidently  the  predis- 
posing cause.  But  in  cases  arising  from  an  internal  cause,  the 
removal  of  that  cause  is  the  principal  objedl. 

Exciting  Causes. — A  fall  on  the  great  trochanter  is  the  most 
frequent  exciting  cause  j  and  fracture  of  the  neck  of  the  femur 


*  De  Co'ilo  Femoiii  ejusqiie  Frnflura  Progranima.   Lipsiae. 
•f-  Traite  des  Maladies  des  Os,  vol.  i.  chap.  2,  art.  j,, 
X  Ibid.  \:  I.  ii. 
\  De  Re  Anatomica. 


OF    FRACTURES    OF    THE    FEMUR,  I0<; 

is  SO  frequently  a  consequence  of  that  accident,  that  when  the 
one  h.is  taken  place,  the  other  is  generally  presumed.  This  ob- 
servation made  by  Citizen  Sabatier*  has  been  confirmed  by  ma- 
ny particular  cases  treated  in  the  principal  hospitals  in  Paris.  A 
fall  on  the  feet  or  knees  sometimes  occasions  a  fradVure  of  the 
neck  of  the  femur,  in  which  case  the  weight  of  the  body  must 
be  thrown  more  on  one  side  than  on  the  other. 

Let  us  examine  the  manner  in  which  this  fradlure  maybe  pro- 
duced. 

When  a  person  falls  on  the  great  trochanter,  the  neck  of  the 
femur  is  a£led  on  by  that  eminence  which  has  ^  point  d'nppition 
the  ground,  and  by  the  body  which  a(Sts  immediately  on  the 
head  of  the  femur.  By  this  action  and  re-a6lion,  a  force  is  ex- 
erted on  the  neck  of  the  femur,  which  tends  to  make  it  paral- 
lel with  the  rest  of  the  bone.  By  this  tendency,  that  part  of 
the  bone  is  curved  beyond  its  natural  extensibility,  and  from 
the  nature  of  the  curve  into  which  it  is  forced,  its  lower  fibres 
break  first,  and  so  on  successively  to  the  superior,  which  break 
last;  on  the  supposition  that  the  rupture  of  these  fibres  was  suc- 
cessive. In  falling  on  the  feet  or  knees,  on  the  contrary,  the 
tendency  of  the  fracluring  cause  is  to  force  the  neck  of  the  fe- 
mur to  forma  right  angle  with  the  bone;  and  the  rupture  of 
the  fibres  must  of  course  commence  in  the  superior. 

From  this  view  of  the  mechanism  of  these  fractures,  it  is  evi- 
dent that  they  are  never  direct,  that  is,  produced  by  a  cause 
acting  immediately  on  the  part;  but  that  they  are,  on  the  con- 
trary, always  the  effevSl  of  a  force  communicated  to  that  part 
hy  contre-cotip  or  transmitted  re-aclionj  as  has  been  observed  by 
Davidf.  The  contusion  which  in  general  is  but  ti-lfling  in  in- 
dlredl  fratTtures,  or  those  ^^^r  contre-cotip^  may  however  be  con- 
siderable in  this  case,  when  produced  by  a  fall  on  the  trochan- 
ter; for  this  reason,  that,  though  the  force  be  transmitted,  yet, 
on  account  of  the  shortness  of  the  neck  of  the  femur,  the  frac- 
ture must  take  place  near  the  part  immediately  afi:e<5led;  so 
that,  with  respeit  to  contusion,  fradtures  of  this  part  may  be 
considered  as  direct. 

Fractures  of  the  neck  of  the  femur  are  always  attended  with 
derangement:  it  is  po-sible,  however,  that  this  derangement 
may  not  take  place  for  a  few  days  after  the  fra(fture.  There 
arc  in  the  Memoirs  of  the  Academy  of  Surgery,  the  particulars 

*  Msm.  At  V  Acad,   de  Chiiiirj^ie 

-}-  Frize-qticstioiis  of  tlie  Academy  of  Surgery,  vol.  iv. 

14. 


Io6  OF    FRACTURES    OF    THE    FEMUR. 

of  a  case  in  which  a  man  after  having  fractured  the  neck  of 
the  femur  by  a  fall,  was  able  to  rise  without  any  assistance,  and 
walk  home  to  his  lodging.  A  similar  case  is  found  in  Desault's 
Journal.  Finally,  a  great  number  of  cases  collected  by  Louis, 
Duverney,  Sabatier,  and  other  authors  of  no  less  authority, 
and  those  observed  by  Citizen  Boyer,  leave  no  doubt  on  the 
possibility  of  a  derangement  ensuing  several  days  after  the 
fraclure.  And  it  is  easy  to  conceive  that  in  a  fra^lure  of  what 
is  properly  called  the  neck  of  the  femur,  the  orbicular  ligament 
may  oppose  the  derangement,  and  counteract  the  aftion  of  the 
powerful  muscles,  which  pass  from  the  pelvis  to  the  lower  frac- 
tured portion,  into  which,  also,  the  orbicular  ligament  is  in- 
serted. 

Another  cause  which  must  contribute  to  prevent  derange- 
ment, is  the  proje(5lions  and  depressions  of  the  surfaces  of  the 
pieces,  which  inequalities  render  lateral  motion  difEcult.  We 
have  already  remarked  this  circumstance,  in  treating  of  the  di- 
rection of  the  fracture,  which,  accurately  speaking,  is  neither 
oblique  nor  transverse. 

The  fraifirures  within  the  articulation  are  never  attended  with 
a  very  considerable  derangement.  The  orbicular  ligament  yields 
a  little  without  being  torn;  the  body  and  neck  of  the  bone,  in- 
stead of  their  oblique  or  angular  position  becomes  redlilinear; 
from  which  change  of  diredlion,  as  well  as  from  a  slight  de- 
rangement in  the  dirC(Slion  of  the  diameter,  arises  the  shorten- 
ing of  the  limb.  Louis  has  asserted  that  the  derangement  may 
be  considerable,  but  has  not  supported  this  assertion  either 
by  facts  or  reasoning.  In  fractures  outside  the  articulation,  or 
between  the  trochanters,  the  muscles  which  tend  to  produce 
the  derangement  act  without  any  opposition  and  draw  the  in- 
ferior fractured  portion  outward,  upward,  and  a  little  back- 
ward toward  the  iliac  depression.  The  great  trochanter  ap- 
proaches the  brim  or  ridge  of  the  iliac  bone,  but  never  passes 
under  the  glutei  muscles,  which  cover  the  surface  of  that 
bone. 

The  action  of  the  muscles  which  are  inserted  into  the  infe- 
rior portion,  and  particularly  that  of  the  glutei,  is  not  the  sole 
cause  of  the  derangement;  that  effect  being  in  part  produced 
by  the  weight  of  the  body,  which  forces  the  pelvis  downward, 
and  with  it  the  superior  portion  of  the  femur:  muscular  a<Stion' 
is  however  the  principal  cause. 

Besides  the  longitudinal  derangement,  that  in  the  circum- 
ference also  takes  place  in  consequence  of  the  rotation  of  tlie 


OF    FRACTURiES    OF    THE    FEMUR.  107 

whole  inferior  extremity  outward.  This  is  effedted  by  the 
weight  of  the  part,  rather  than  by  the  allien  of  the  rotatory 
muscles.  If  the  rotation  of  the  Uinb  were  produced  by  the  con- 
tra£lion  of  these  muscles,  there  would  be  more  difficulty  in 
bringing  the  foot  to  its  natural  position,  or  in  inclining  it  in- 
ward, than  in  reality  is  found  in  bringing  it  in  any  of  these  di- 
retStions.  But  in  order  to  be  fully  convinced  of  the  cause  of 
this  rotation,  it  is  only  necessary  to  observe  the  position  which 
the  inferior  extremiry  assumes,  when  a  person  laid  horizontally 
on  his  back  abandons  it  to  its  own  weight:  in  such  a  case  the 
foot  and  knee  incUne  constantly  outward. 

The  derangement  may  take  place  internally,  either  by  a  par- 
ticular disposition  of  the  extremity,  by  the  pressure  of  the 
bej-clothes,  or  some  such  cause.  Pare  and  Petit  describe  the 
derangement  as  having  taken  place  internally,  in  all  the  cases 
of  this  kind  that  occurred  to  them.  Louis  has  endeavoured  to 
give  a  favourable  turn  to  the  report  of  Pare.  He  says  that  Pare 
meant  merely  to  state  that  the  foot  was  separated  from  the  op- 
posite leg  by  a  less  interval  than  the  knee  of  the  same  side; 
which  observation  is  true  in  a  certain  sense,  even  when  both 
are  turned  outward.  As  to  Petit  we  must  either  suppose  that 
a  deference  for  the  opinion  of  Pare  led  him  into  an  error  of  fact 
or  expression,  or  that  the  mistake  originated  with  the  copyist 
or  printer.  But  since  the  publication  of  Louis's  explanation  in 
the  Memoirs  of  the  Academy,  the  possibility  of  derangement 
inwards  has  been  ascertained  by  observation.  Desault  conclu- 
ded from  his  experience  that  the  rotatory  derangement  inward 
"was  to  that  outward  as  1   :  4. 

Diagnosis. — The  resemblance  between  the  symptoms  of  this 
fracture  and  luxation,  has  frequently  occasioned  these  two  af- 
fedlions  to  be  confounded  witli  one  another.  Thus  we  find 
that  luxation  of  the  femur  was  known  to  the  ancients,  and  that 
fradture  of  the  neck  of  that  bone  was  unknown  until  described 
by  Pare.  He  is,  at  least  the  first  author  who  has  given  any 
clear  and  positive  information  on  that  subjedl.  Since  his  time, 
observations  on  the  nature  of  this  afFeftion  have  been  multipli- 
ed; but  as  yet  authors  are  not  agreed  as  to  the  symptoms  by 
which  it  is  distinguished. 

Fradture  of  the  neck  of  the  femur  is  so  frequent  a  conse- 
quence of  a  fall  on  the  great  trochanter,  that  the  former  ha- 
ving taken  place,  renders  the  other  highly  probable:  an  acute 
pain  felt  in  the  articulation  augments  that  probability.  But  the 
fell  or  pain  which  may  not  exist  even  when  the  fracture  has 


I08  OF    FRACTURES    OF    THE    FEMUR. 

taken  place,  as  in  a  case  related  by  Duvcrney,  are  equivocal, 
or  at  best  but  corroborating  circumstances.  The  sensible  signs 
are  those  alone  on  which  the  diagnosis  is  to  be  founded :  they 
are  as  follows: 

It  sometimes  happens,  that  in  the  moment  of  falling  the  pa- 
tient hears  a  crack  in  the  articulation,  and  remains  without  the 
power  of  raising  himself.  Shortening  of  the  limb  is  a  conse- 
quence of  this  fra6lure;  but  as  that  does  not  always  take  place 
immediately,  it  cannot  assist  in  forming  the  diagnosis  in  every 
case;  but  the  uncertainty  arising  from  tlie  want  of  that  sign  is 
quickly  removed,  for  the  shortness  supervenes  in  a  few  days.  It 
may  not  be  superfluous  to  remark,  that  in  ascertaining  the 
shortness  of  the  limb,  the  patient  should  be  laid  supine  on  an 
horizontal  plane,  and  the  pelvis  so  placed  as  that  its  anterior 
and  superior  spinous  processes  may  be  in  the  same  horizontal 
line. 

The  point  of  the  foot  is  turned  outward,  as  is  the  knee,  and 
the  l-jg  bent  so  as  that  the  heel  is  turned  inward,  and  placed  be- 
hind the  ankle  of  the  other  foot,  in  the  depression  between  the 
annie  and  tendo  Achiliis. 

It  very  rarely  happens  that  the  heel  is  placed  above  the  an- 
kle, except,  however,  when  the  fracture  is  outside  the  articu- 
Lation,  and  the  longitudinal  derangement  very  consiJerable. 
In  fractures  of  the  part  strictly  called  the  neck,  it  would  be 
necessary,  in  order  that  the  ankle  should  be  so  placed,  that  the 
fravSture  had  been  produced  by  a  fall  on  the  feet  or  knees  from 
a  great  height,  and  that  the  orbicular  ligament  had  been  en- 
tire! 7  torn,  of  which  no  example  has  as  yet  been  observed. 

The  limb  may  be  brought  to  its  natural  length  by  means  of 
extension  and  counter-extension,  but  it  shortens  again  instant- 
ly if  left  to  itself.  The  foot  may,  with  great  facility,  be  placed 
in  its  natural  position,  without  causing  in  any  degree  the  pain 
and  suffering  which  Citizen  Sabatier  seems  to  have  apprej  end- 
ed •,  he  says,  that  the  attempt  is  imprudent,  and  the  motion 
difficult.  The  asperities  of  the  broken  pieces  can  seldom  irritate 
or  lacerate  the  soft  partSj  because  the  orbicular  ligament  is  sel- 
dom entirely  torn:  to  that  cause,  however.  Citizen  Sabatier 
attributes  the  pain  and  difficulty,  which  he  considers  as  being 
so  formidable 

In  bringing  the  limb  into  its  natural  diretStion,  the  fractured 
surfaces  are  rubbed  one  against  the  other  j  and  this  friction, 
more  or  less  considerable  according  to  the  asperity  of  the  sur- 
faces, produces  a  crepitation,  which  is  one  of  the  surest  signs 


OF    FRACTURES    OF    THE    FEMUR. 


109 


of  fra^ure.  It  has  been  asserted  by  some  writers,  that  the 
great  depth  of  soft  parts  prevents  the  crepitation  from  being 
heard,  whieh  for  that  reason,  say  they,  can  be  no  sign  of  this 
fraiSlure.  But  the  clear  and  distin(St  perception  of  the  noise  is 
a  better  proof  of  its  existence  than  any  reasoning  can  be  of  its 
impossibihty;  and  we  assert,  that  it  is  possible  in  most  cases  to 
tear  it.  I  have  myself  frequently  heard  it,  by  applying,  it  is 
true,  a  very  attentive  ear. 

In  turning  the  limb,  in  order  to  place  the  foot  straight,  or 
to  incline  it  inward,  the  gfeat  trochanter  will  be  found,  by 
placing  the  hand  on  it,  to  move  in  a  very  small  space,  or,  as  it 
were,  on  itself  pivot-like.  But  in  the  rotation  of  the  thigh 
in  its  natural  state,  that  eminence  describes  an  arch  ol  a  circle, 
the  radius  of  whieh  is  composed  of  the  length  of  the  neck  and 
head  of  the  femur  ;  but  after  the  fradlure,  the  diameter  of  this 
circle  is  composed  of  the  diameter  of  the  bone  and  of  that  part 
of  the  neck  which  remains  below  the  fracture.  Whence  we 
may  conclude,  that  arches  described  by  the  great  trochanter  in 
cases  of  fraiSture  of  the  neck  of  the  femur,  will  be  so  much  the 
greater,  as  the  fracture  takes  place  nearer  the  head,  and  that  this 
arch  will  be  at  its  maximum  in  the  case  of  decollation  of  tJie 
epiphysis.  In  order  to  appreciate  this  sign  it  will  be  necessary 
to  compare  the  arches  described  by  the  trochanter  of  the 
fra£lured  member  with  those  described  by  that  of  the  opposite 
side. 

When  the  fracture  is  outside  the  articulation,  the  trochanter 
appears  less,  and  is  nearer  the  ridge  of  the  ossa  ilia  than  in  the 
natural  state.  The  buttock  is  also  rounder  than  natural,  011 
account  of  the  relaxation  of  the  muscles. 

Another  sign  of  which  authors  have  made  no  mention,  but 
which  is  constant,  is  the  impossibility  of  raising  the  member 
all  at  once;  that  is,  of  bending  the  thigh  on  the  pelvis,  the 
leg  being  extended  on  the  thigh.  It  is  necessary  for  the  exe- 
cution of  this  motion,  that  the  limb  have  a  point  d'appui  in  the 
acetabuluni:  it  may  be  compared  to  the  circular  motion  with 
which  the  hand  is  raised  to  the  forehead,  and  which  is  imprac- 
ticable when  the  humerus  has  lost  its  point  d" appui  by  a  fracture 
of  the  clavicle.  In  attempting  to  raise  the  thigh,  the  patient 
first  bends  the  leg  analogously  to  the  effort  made  to  bring  the 
hand  to  the  forehead,  by  bending  the  fore- arm.* 

*  It  will  always  be  easy  to  d  stinguish  the  imposs  b  lity  of  this  motion 
resulting  fiom  puin,  tVoni  that  resulting  horn  the  want  ct'  a  point  d^cppui 


IIO  OF    FRACTURES    OF    THE    FEMUR. 

According  to  Louis,  much  pain  is  produced  by  moving  the 
fraftured  limb  from  that  of  the  opposite,  and  none  at  all  by 
the  contrary  motion:  this  difference  he  attributes  to  the  action 
of  the  lower  fractured  portion  on  the  soft  parts  of  the  external 
side,  and  considers  the  pain  caused  thereby  as  a  distindlive  sign 
of  the  fracture.  We  have  already  said,  that  a  derangement  as 
considerable  as  that  supposed  by  Louis  never  takes  place.  If  it 
really  did,  adduilion  and  abdudtion  ought  to  be  equally  painful; 
and,  in  fadl,  every  motion  given  the  limb,  no  matter  m  what 
diredlion,  causes  more  or  less  pain;  but  pain,  however  produ- 
ced, is  a  very  equivocal  sign,  as  it  belongs  equally  to  all  dis- 
eases of  the  articulation. 

Of  all  affeftions,  there  is  none  so  easily  confounded  with 
the  fradture  of  which  we  are  treating  as  the  different  species 
of  luxation  of  which  the  thigh  is  susceptible.  The  luxation 
upward  and  outward  is  the  most  easily  mistaken  for  fracSture, 
notwithstanding  the  two  affections  have  in  common  only  the 
shortening  of  the  member.  The  impossibility  of  restoring  the 
limb  to  its  natural  length  by  a  gentle  effort,  its  permanence  in 
the  natural  situation  when  once  restored,  and,  before  that  is 
done,  the  impossibility  of  turning  the  foot  outward,  which  has 
been  carried  inward,  are  signs  by  which  that  species  of  luxa- 
tion can  be  easily  distinguished  from  fradture  of  the  neck  of 
the  femur. 

In  the  luxation  inward  and  upward,  In  which  the  head  of 
the  femur  is  propelled  toward  the  pubis,  the  extremity  is 
shortened,  and  the  foot  turned  outward ;  neither  of  which  cir- 
cumstances can  be  corrected  without  antecedently  restoring  the 
femur  to  its  natural  situation. 

Luxations  downward,  whether  inward  or  outward,  can  ne- 
ver be  mistaken  for  this  fracture,  because  in  these  the  member 
is  always  lengthened. 

The  secondary,  or  spontaneous  luxation  of  the  femur,  is  al- 
ways preceded  by  dull  pains  felt  in  the  superior  and  inferior  ar- 
ticulations of  that  bone;  it  is  further  characterized  by  a  gradu- 
al elongation  of  the  member,  and  then  by  a  sudden  shortening 
and  a  diminution  in  the  interval  which  separates  the  great  tro- 
chanter from  the  ridge  of  the  iliac  bone;  by  the  inclination  in- 
ward of  the  foot  and  knee;  finally,  by  all  the  symptoms  of  lux- 
ation upward  and  outward,  joined  to  the  induration  of  the  soft 

for  the  ferhiir.    This  impossibility  remaining  after  the  inflammntory  symp- 
toms have  ceased,  will  always  be  a  pathognomonic  sign. 


OF    FRACTURES    OF    THE    FEMUR."  Ill 

parts,  the  abscesses  which  form  in  these  parts,  and  which  ter- 
minate in  fistulse.  All  these  signs  leave  no  possibility  of  its 
being  mistaken  for  a  fradlure  of  the  neck  of  the  femur,  an 
affe(Stion  with  which  it  has  nothing  in  common,  except  indeed 
that  the  spontaneous  luxation  is  sometimes  produced  by  the 
same  cause  as  the  fradl:ure,  namely,  a  fall  on  the  foot,  knee, 
or  great  trochanter,  by  which  the  cartilages  of  the  articulation 
are  contused.  The  irritation  caused  by  this  contusion  produces 
a  turgescence  and  swelling  of  the  cartilages  and  cellular  tex- 
ture that  accompanies  the  round  ligament.  This  tumefadlion 
augments  until  the  acetabulum  is  entirely  filled,  and  the  head 
of  the  femur  expelled  from  that  cavity. 

It  appears,  then,  that  a  striiSt  comparison  of  the  symptoms 
will  enable  the  surjreoJi  to  distinguish  a  fracture  of  the  neck  of 
the  femur  from  any  affection  of  the  hip  joint.  But  we  must 
acknowledge,  en  the  other  hand  that  fractures  of  this  part  of 
the  femur,  which  are  without  any,  or  with  very  little  derange- 
ment, are  not  always  very  easy  to  be  ascertained  or  distinguish- 
ed. An  old  man  fell  on  the  great  trochanter,  and  the  length 
of  the  extremity  of  that  side  was  found  to  have  diminished 
half  an  inch  in  consequence  of  this  fall;  but  there  was  no  other 
symptom  of  frafture.  '  Citizen  Boyer  pronounced  the  existence 
of  a  fra(5lure  of  the  neck  of  the  femur,  and  a  second  surgeon 
confirmed  this  decision.  A  third  pra^lltioner  was  not  clearly 
of  the  same  opinion;  but  remarked  that  the  shortening  might 
be  owing  to  the  contra(Slion  of  the  muscles;  but  as  there  was 
no  symptom  of  that  contraction  which  could  not  produce  the 
shortening  of  the  limb  without  nearly  obliterating  at  the  same 
time  the  interarticular  cartilages,  the  apparatus  for  fracture  was 
applied,  because,  whichever  opinion  was  the  true  one,  no  in- 
convenience or  evil  could  result  from  its  application.  The  pa- 
tient died  of  an  ascites  in  five  days.  On  dissefting  the  articu- 
lation of  the  thigh,  a  fra<Sture  of  the  neck  of  the  femur  was 
found,  and  consolidation  had  commenced,  though  it  had  ad- 
vanced but  very  little. 

We  shall  recapitulate  in  a  few  words  what  distinguishes  this 
fracture:  a  fall  on  the  great  trochanter  followed  by  pain  in 
the  articulation,  with  the  impossibility  of  bending  the  thigh 
on  the  pelvis,  the  leg  being  extended  on  the  thigh;  shortness 
of  the  extremity,  which  is  easily  removed,  but  returns  as  soon 
as  the  extending  force  is  discontinued;  an  inclination  of  the 
foot  and  knee  outward,  with  great  facility  of  moving  these  parts 
to  their  natural  situation;  crepitation  produced  in  eiiccting dif- 


112  OF    FRACTURES    OF    THE    FEMUR. 

ferent  movements;  and  the  smallness  of  the  circle  in  which  the 
great  trochanter  moves  in  a  rotatory  motion.  We  can  seldom 
be  mistaken  as  to  the  existence  of  this  fracture,  if  we  attend 
to  all  these  circumstances. 

When  the  want  of  any  important  symptom  renders  the 
case  doubtful,  the  apparatus  should  however  be  applied,  as  no 
danger  can  result  from  its  application,  provided  the  inflamma- 
tory symptoms  have  disappeared.  It  generally  happens  that  in 
a  few  days  the  shortening  of  the  extremity  removes  any  doubt 
that  might  have  been  entertained;  and  this  shortening,  as  we 
have  already  mentioned,  may  be  retarded  by  the  mutual  inser- 
tion of  the  fradlured  surfaces,  or  by  the  resistance  of  the  orbi- 
cular ligament. 

The  prognosis  of  fra^lures  of  the  neck  of  the -femur  is  very 
difficult  to  establish.  Some  authors  consider  them  as  highly 
dangerous,  always  occasioning  inflammation  of  the  cartilages 
and  surrounding  soft  pai*ts.  Morgagni*  has  made  some  obser- 
vations, which  tend  to  give  weight  to  thi*  unfavourable  prog- 
nosis. Others,  on  the  contrary,  consider  these  disagreeable 
consequences  as  extremely  rare,  so  much  so  as  never  to  have 
met  them  in  their  praflice.  This  we  can  say,  that  these  frac- 
tures are  never  followed  by  secondary  or  spontaneous  luxation 
of  the  femur,  which  proves  that  the  contusion  of  the  cartila- 
ges has  not  been  excessive,  and  that  probably  the  whole  force 
was  spent  in  efFefling  the  frafture. 

The  difference  of  opinion  on  the  prognosis  of  this  affection 
does  not  regard  merely  the  inflammation  and  abscesses  which 
it  may  occasion,  and  the  fistulx  w^hich  result  from  these  ab- 
scesses. Some  authors  are  of  opinion,  that  the  shortening  of  the 
limb  can  by  no  means  be  guarded  against;  and  others,  that  the 
consolidation  of  the  fraflure  cannot  be  at  all  efFefted.  There 
are  some,  however,  who  aflirm  that  the  consolidation  is  ob- 
tained in  this  case  as  in  any  other.  As  the  treatment  must  be 
accommodated  to  whichever  of  these  opinions  is  adopted,  it  is 
necessary  to  consider  carefully  the  greater  or  less  probability 
of  each,  how  far  any  of  them  may  be  true,  and  the  restrifli- 
ons  which  they  may  require;  and  to  consider,  in  short,  in  what 
particulars  they  may  serve  to  dire^  the  treatment.  By  recur- 
ring to  what  we  have  already  advanced  on  the  formation  of 
callus,  and  on  the  different  theories  on  that  subje<Sl,  we  shall 
acquire  at  once  a  solution  of  the  problem. 

*  hlorg3gr[\  Je  Causis  et  Sedibus  Morb.  EjM>t.  56. 


OF    FRACTURES    OF    THE    FEMUR.  n^ 

Thus  those  who  have  admitted  the  existence  of  an  osseous 
humour  from  which  the  callus  is 'formed,  have  argued,  that 
fractures  of  the  neck  of  the  femur  cannot  be  cured,  because 
this  osseous  humour  is  perpetually  diluted  by  the  synovia,  with 
which  the  broken  ends  must  always  be  moistened.  The  par- 
tisans of  Duhamel's  opinion  have  given  as  a  reason  for  the  sup- 
posed non-consolidation  of  this  fraiSture,  the  want  of  the  pe- 
riosteum on  that  part.  But,  in  fa<St,  it  is  furnished  with  a  pe- 
riosteum by  the  fibrous  duplicature  of  the  orbicular  ligament 
which  is  refledled  round  it,  and  which,  provided  itself  with  a 
very  vascular  texture,  transmits  to  the  bone  the  vessels  that 
nourish  it.  But  fatSts,  which  attest  the  possibility  of  consoli- 
dation, render  it  unnecessary  to  enter  into  any  verbal  refuta- 
tion of  assertions  and  theories.  Numerous  instances  of  reco- 
very are  related,  and  preparations  which  prove  that  consolida- 
tion had  taken  place,  are  to  be  met  in  many  anatomical  col- 
leftions.  The  consolidation  is,  doubtless,  slower  and  more 
difficult  in  this  than  in  other  parts,  but  the  difference  in  the 
time  necessary  for  cure  may  be  easily  accounted  for  by  our 
theory  of  the  formation  of  callus. 

The  possibility  of  the  consolidation  of  a  fra6lure  supposes 
that  each  of  the  broken  portions  is  endued  with  a  certain  de- 
gree of  vitality:  the  splinters  of  bone  which,  in  comminutive 
fracture,  are  totally  detached,  never  reunite.  In  fraifture  of 
the  neck  of  the  femur,  the  inferior  portion  is  endued  with  all 
the  conditions  necessary  to  a  prompt  reunion;  but  the  superior, 
on  the  contrary,  enclosed  entirely  in  the  acetabulum,  and  in 
contadl:  only  with  the  cartilaginous  surface  of  that  cavity  and 
with  the  orbicular  ligament,  has  no  connexion  with  the  rest 
of  the  body,  but  by  means  of  the  round  ligament  which  con- 
veys to  it  a  few  blood  vessels,  but  which  are  not  sufficient  for 
giving  its  vascular  texture  the  degree  of  turgescence  necessary 
for  the  generation  of  callus.  In  most  cases,  the  duplicature  of 
the  orbicular  ligament,  which  we  have  already  described,  is 
but  partially  torn,  and  a  communication  between  the  vessels  of 
the  head  of  the  femur,  and  those  of  the  other  parts,  is  pre- 
served, by  means  of  which  the  consolidation  is  principally  ef- 
fected. To  the  complete  rupture  of  the  orbicular  ligament* 
ought  probably  to  be  attributed  the  non-consolidation  of  some 

*  The  motion  communicated  to  tlie  limb,  in  order  to  produce  crepita- 
tion, alv/ays  obscure,  may  aid  in  completing  the  lupture ;  for  which  rea- 
son the  trial  ought  not  to  be  made  without  the  greatest  cuution. 

15 


114.  OF    FRACTURES    OF    THE    FEMUR. 

cases  of  fra^lure.  Old  age  is,  however,  the  most  frequehf 
cause  of  non-consolidation:  and  those  who  are  of  opinion  that 
the  fradlure  of  the  neck  of  the  femur  is  incurable,  endeavour 
to  support  that  opinion  by  instances  of  this  kind  in  old  persons. 
Ruisch  cites  many  cases  communicated  to  him  by  Gerard 
Borst,  who  was  physician  to  an  hospital  of  old  women  at  Am- 
sterdam, in  Avhich  a  recovery  could  not  be  cffecled.  In  these 
persons  great  age  v/aa  an  invincible  obstacle  to  the  formation 
of  the  callus,  and  was  the  sole  reason  why,  after  death,  the 
head  of  the  bone  was  found  diminished,  decayed,  and  con- 
verted into  a  kind'  of  ligamentous  cap. 

I  dare  say  too,  that  the  great  hospitals  of  Paris  destined  for 
the  recepiiqn  of  aged  persons,  as  La  Salpetriere  and  the  Hos- 
pital of  Invalids,  could  furnish  instances  of  the  same  kind  suf- 
ficient to  warrant  the  induction  that  this  fracture  is  incurable 
,beyond  a  certain  age,  if  not  sufficient  to  lead  into  error  by  too 
general  an  application  of  particular  fa£ts. 

It  is  not  in  our  power,  however,  to  mark  precisely  the  pe- 
riod beyond  which  a  cure  is  not  to  be  hoped  for.  To  be  able 
to  settle  this,  it  would  be  necessary  that  the  cfFecfcs  of  old  age 
were  uniform  in  every  individual,  and  that  the  degree  of  se- 
nility were  always  commensurate  with  the  number  of  years. — - 
Lesne  shewed,  at  the  Academy  of  Surgery,  the  femur  of  a 
woman  aged  eighty-nine,  with  marks  of  a  consolidated  fracture 
of  its  neck.  I  have  pubUshed  the  case  of  a  man  aged  eighty- 
three,  in  whom  the  consolidation  of  a  double  fracture  Avas  con- 
siderably advanced.  Numerous  fa6ts  of  this  nature  authorize 
and  require  the  application  of  the  apparatus  in  all  cases,  except 
where  the  patient,  reduced  to  the  last  stage  of  decrepitude  and 
debility,  cannot  support  its  v/eight,  or  is  attacked  by  some 
mortal  disease.  But  at  the  same  time,  the  surgeon  should,  for 
his  own  sake,  accjuaint  the  patient  and  his  friends  with  the  un- 
certainty of  the  cure,  in  order  to  ward  off"  any  imputation 
that  might  be  made  in  case  of  failure. 

Authors  who  have  considered  the  consolidation  as  impossi- 
ble, have  ascribed  to  that  cause  the  shortening  of  the  limbj 
whilst  others,  partisans  of  the  opposite  opinion,  have  however, 
considered  the  shortening  and  lameness  as  uniformly  arising 
from  the  improper  position  of  the  fradturcd  pieces;  the  lower 
of  which,  say  they,  slides  on  the  superior,  obeying  the  con- 
traction of  the  muscles  v/hich  draw  it  upward,  so  that  tlve 
fractured  surfaces  can  no  longer  correspond  cxaftly,  and  the 
niciiiber  becomes  necessarily  shortened  in  proportion  to  the 


OF    FRACTURES    OF    THE    FEMUR,  I  15 

ascent  of  the  inferior  fraftured  portion,  and  diminution  of  the 
obtuse  angle  formed  by  the  neck  of  the  femur  with  the  body 
of  that  bone.  Or  it  may  happen  that  the  fractured  surfaces 
shall  have  no  point  of  mutual  contaclj  that  the  angle,  from 
oblique,  shall  become  right,  or  nearly  so;  and  that  the  union 
shall  be  eftecled  by  means  of  a  ligamento-cartilaginous  substance: 
a  case  of  this  kind  has  probably  given  rise  to  the  opinion  that 
the  reunion  of  these  fracftures  was  analogous  to  that  of  the 
patella  and  olecranon. 

Fabricius  Hildanus,  Platner,  Ludvvig,  S:c.  have  positively 
asserted,  that  a  recovery  without  shortening  and  lameness  was 
impossible.  Louis  and  Citizen  Sabatier  appear  to  have  adopted 
the  same  opinion,  which,  however,  is  now  known  to  be  erro- 
neous from  the  success  obtained  in  various  cases.  Of  this  suc- 
cess, Desault's  practice  furnishes  many  instances;  from  that  of 
Citizen  Boyer,  which  has  been  equally  extensive  and  success- 
ful, I  shall  content  myself  with  citing  one  example. 

A  strong  robust  hackney-coachman  fell  from  the  box,  and 
fractured  the  neck  of  the  femur;  the  great  trochanter  having 
borne  the  rea<fi:ion  of  the  fall.  The  contusion  was  such  as 
might  be  expedled  from  the  height  of  the  fall  and  the  person's 
weight.  Four  hours  after  the  accident,  when  he  was  convey- 
ed to  La  Charitey  on  the  20th  Prairial,  5th  year,  the  swelling 
and  tension  were  extrem.e.  Emollient  poultices  were  applied, 
bleeding  and  an  antiphlogistic  regimen  were  prescribed.  The 
limb  being  but  little  shortened,  afforded  a  ground  of  presuming 
that  the  fracture  was  within  the  articulation.   On  the  subsiding: 

o 

of  the  inflammatory  symptoms,  the  apparatus  for  making  conti- 
nued extension  was  applied,  and  reapplied,  as  often  as  its  relax- 
ation rendered  it  necessary.  Gangrenous  eschars  were  formed 
on  the  instep  and  tendo  Achillis,  although  thick  compresses 
were  placed  between  these  parts  and  the  pieces  of  the  appara- 
tus: it  is  possible,  however,  that  they  might  have  been  pre- 
sented, had  the  patient,  a  man  of  nncomrnon  firmness  and 
courage,  complained  of  the  pressure  being  too  great.  The  re- 
union was  complete  on  the  fiftieth  day,  as  was  proved  by  the 
motion  of  the  whole  limb:  on  the  sixtieth  day  the  patient 
quitted  his  bed,  and  walked  about  with  crutches;  and,  at  the 
end  of  three  months,  left  the  hospital  perfectly  recovered, 
there  being  then  no  perceptible  difference  in  the  length  of  his 
two  inferior  extremities. 

It  is  then  established  by  what  prec-edes,  that  a  cure  without 
lameness  may  be  obtained^  as  well  as  a  perfect  consolidation. 


Il6  OF    FRACTURES    OF    THE    FEMUR. 

but  by  means,  It  is  true,  unknown  till  lately.  It  is  not  surpri- 
sing that  surgeons,  unacquainted  with  this  means,  supposed 
lameness  an  inevitable  consequence  of  fractures  of  the  neck  of 
the  femur. 

The  general  causes  which  retard  or  prevent  the  formation  of 
callus  will  affedl  fractures  of  the  neck  of  the  femur  more  than 
any  other,  because  the  formation  of  the  callus  is  slower  there 
than  in  any  other  part;  for  which  reason  every  motion  should 
be  particularly  avoided,  as  well  as  every  other  circumstance 
that  might  disturb  the  generation  of  callus.  In  this  case  more 
than  in  any  other,  a  disposition  to  cancer,  scurvy,  &c.  is  un- 
favourable, and  a  state  of  general  debility  is  also  injurious;  it 
should,  therefore,  be  combated  with  extraordinary  vigilance. 
Pregnancy,  which  we  suppose  to  be  in  general  of  little  or  no 
effect,  might,  however,  diminish  the  probability  of  a  perfe^ 
consolidation  of  a  fracSture  of  the  neck  of  the  femur. 

The  particular  objefts  to  which,  in  treating  these  fractures, 
we  are  to  dire6t  our  attention,  are  no  other  than  those  already 
mentioned  in  general,  namely,  to  set  the  bone,  keep  the 
pieces  in  their  place,  and  combat  any  unfiivourable  symptom 
that  may  arise.  The  means  of  effetfting  extension  and  coun- 
ter-extension are  the  same  as  in  other  fractures  of  the  femur, 
and  for  the  same  general  reasons  as  mentioned  in  treating  of 
the  fracture  of  the  body  of  that  bone.  If  it  be  necessary  to 
employ  a  great  number  of  assistants,  a  cloth,  on  which  each 
may  pull,  should  be  rolled  on  the  inferior  part  of  the  leg,  and 
tw^o  others  round  the  pelvis;  the  extremities  of  one  of  which 
should  be  joined  and  held  above  the  hip  of  the  side  affefted, 
for  the  purpose  of  making  counter-extension;  whilst  another 
should  be  brought  in  the  opposite  dire(Stion,  and  held  by  a  suf- 
ficient number  of  assistants,  in  order  to  prevent  the  pelvis 
from  being  drawn  to  the  fraftured  side.  The  joint  adtion  of 
these  two  last  mentioned  means  of  counter-extension  is  neces- 
sary to  render  the  pelvis  immovable.  In  most  cases,  however, 
this  purpose  is  answered  by  simpler  means. 

Previous  to  any  attempt  to  remedy  the  longitudinal  derange- 
ment by  means  of  extension  and  counter-extension,  it  will 
be  necessary  to  corredt  that  of  the  circumference,  by  gi- 
ving tlie  foot  its  natural  direction.  Coaptation  is  a  part  of  the 
operation  totally  useless  in  setting  a  fradturc  of  the  neck  of  the, 
femur,  on  account  of  the  greath  depth  of  soft  parts,  and  the 
total  impossibility  of  a^ing  on  the  superior  piece  of  bon^. 


OF    FRACTURES    OF    THE    FEMUR,  II7 

If  on  the  first  attempt  to  extend  the  limb,  the  muscles  are 
found  to  contract  powerfully,  it  will  be  useless  to  continue  ef- 
forts painful  and  fruitless  for  the  patient.  The  best  practice  to 
be  adopted  then,  is  to  apply  the  apparatus  for  fra^ures  of  the 
body  of  the  bone,  draw  some  blood  from  the  patient,  put  him 
on  an  antiphlogistic  regimen,  and  wait  the  removal  of  the  spas- 
modic state.  This  state  is  much  less  frequent  in  the  fradlures 
of  the  neck  of  the  femur  than  in  those  of  the  body  of  that 
bonej  because  in  the  former  the  fractured  ends  are  within  the 
orbicular  ligament,  and  cannot  therefore  irritate  the  soft  parts. 
When  it  was  customary  to  apply  the  extendmg  force  above  the 
knee,  and  the  counter-extending  to  the  groin,  the  spasmodic 
state  was  much  more  frequent  than  since  the  present  improved 
practice  has  been  adopted. 

The  difficulty  of  keeping  the  pieces  in  their  place  in  a  frac- 
ture of  the  neck  of  the  femur  is  inversely  proportional  to  the 
facility  with  which  the  setting  is  effefted;  for  which  reason  the 
jnefficacy  of  the  ordinary  means  has  been  long  ago  acknow- 
ledged in  oblique  fractures  of  the  body  of  that  bone,  as  well  as 
in  fractures  of  its  neck.  Different  expedients  have  been  devi- 
sed at  different  periods,  to  remedy  this  disadvantage.  We  shall 
compare  their  merits,  after  first  considering  the  position  in 
which  the  limb  should  be  placed. 

The  half-bent  state  recommended  by  Pott  for  the  inferior  as 
well  as  superior  extremity,  is  attended  with  a  great  number  of 
inconveniences,  the  mention  of  some  of  which  will  suliice  for 
its  rejedtion;  the  facility  with  which  the  limb  changes  from 
that  position,  the  difficulty  of  applying  the  apparatus,  the  im- 
possibility of  comparing  the  length  of  the  limb  with  that  of  the 
opposite  side;  finally,  the  pain  produced  by  the  continual 
pressure  on  the  great  trochanter,  and  the  gangrene  which  en- 
sues. 

In  fracture  of  the  neck  of  the  femur,  as  in  all  those  of  the 
inferior  extremity,  the  leg  should  be  extended  on  the  thigh, 
and  the  thigh  on  the  pelvis.  This  position  must  be  secured  by 
means  of  an  apparatus,  on  the  invention  of  which  the  imagi- 
nation of  practitioners  and  theorists  has  been  very  a6tive.  The 
expedients  for  effedling  this  are  so  numerous,  that  a  descrip- 
tion of  them  would  lead  us  too  far  from  our  objecl:.  Studious  to 
avoid  any  superfluous  details,  and  equally  so  any  important  omis- 
sion, we  shall  range,  in  two  classes,  the  different  apparatus:  in 
the  first,  those  which  do  not  effect  any  extension;  in  the  se- 
cond, those  which  do. 


Il8  OF    FRACTURES    OF    THE    FEMUR. 

Several  authors  have  recommended  the  spica  bandage  of  the 
groin,  composed  of  a  piece  of  linen  cloth,  of  a  considerable 
breadth,  and  long  enough  to  be  rolled  round  the  pelvis  several 
times.  This  bandage  being  rolled  up  in  one,  is  drawn  three  or 
four  times  round  the  pelvis,  and  then  several  times  obliquely 
on  the  superior  part  of  the  thigh,  by  directing  it  towards  the 
great  trochanter,  thence  round  the  body,  and  so  successively  j 
but  instead  of  fixing  the  fra<5lured  portions,  it  contributes  to 
derange  them.  As  much  of  it  as  is  applied  on  the  pelvis,  is  ab- 
solutely useless-,  and  the  oblique  casts,  upward  and  outward, 
can  have  no  other  effedl  than  that  of  deranging  the  lower  por- 
tion of  bone-,  that  Is,  of  causing  its  ascent  to  the  external  iliac 
depression.  Finally,  the  application  of  the  spica  requires  that 
the  limb  be  supported  and  raised  up  from  the  bed,  which  can- 
not be  done  without  disturbing  the  generation  of  the  callus. 
This  objeiflion  is  of  the  greatest  importance,  because  the  spica 
requires  to  be  frequently  renewed,  as  It  relaxes  quickly,  and  is 
soon  soiled  with'the  patient's  urine  and  fasces. 

The  eighteen-tailed  bandage,  and  the  fanons  or  faux-famny. 
■with  which  it  is  assisted,  aift  only  on  the  inferior  portion  of  bone, 
yield  like  it  to  the  causes  of  derangement,  andean  therefore  be 
of  no  utility.  And  even  though  this  bandage  should  adt  on 
both  the  fractured  portions,  it  is  now  well  ascertained,  that 
bandat^es,  whatever  may  be  their  constru<5l:ion,  can  contribute 
but  very  little  to  the  confining  of  pieces  of  a  broken  bone  ;  and 
that,  relatively  to  that  obje(fh,  the  effect  of  this  as  well  as  of  the 
others,  is  absolutely  null.  As  to  \X\q.  fanons  ovfaiix-fanons,  their 
circular  shape  admits  them  to  act  only  by  single  points,  or  a 
single  line  of  contact;  for  which  reason  their  effedt  can  be  but 
very  trifling.  Besides,  if  the  bands  by  which  they  are  secured 
be  drawn  tight,  they  "will  necessarily  be  displaced  by  sliding 
backward  or  forward. 

Others  have  employed  long  splints,  of  which  the  external 
ascended  on  the  ribs,  and  the  anterior  on  the  abdomen;  buth 
of  which,  and  the  Internal  splint,  extended  beyond  the  foot. 
Tlie  depressions  were  filled  with  some  kind  of  stufHng,  in  or- 
der to  procure  an  equable  pressure;  and  the  splints  were  kept 
applied  to  the  limb  by  ribbands  or  tape,  and  secured  at  their  su- 
perior extremities  by  a  roller  passed  round  the  trunk,  the  im- 
mobility of  which,  with  respe6t  to  the  limb,  was  one  of  the 
obje<5ts  proposed.  But  this  immobility  of  the  body  could  not 
prevent  the  glutei  muscles,  as  well  as  all  the  others,  v/hich  ex- 
tend from  the  pelvis  to  the  femur  or  leg,  from  drawing  the  ia- 


or    FRACTURES    OF    THE    FEMUR.  11^ 

flerior  portion  of  the  femur  upward  and  outward ;  for  which 
reason  this  means  has  been  abandoned,  though  it  has,  over  the 
two  preceding,  the  advantage  of  correcting  the  derangement 
in  the  circumference.  Dalechamp  hit  on  the  expedient  of 
fastening  the  leg  to  the  foot  of  the  bed  ;  but  as  the  body  was 
not  fixed,  it  slipped  down  and  rendered  this  precaution  useless. 
To  these  may  still  be  added,  the  tin  trough,  lined  with  fustian, 
invented  by  Fabricius  Hildanus,  and  in  which  the  outside  of 
the  thigh  was  placed,  the  oblique  bandages,  and  all  that  as- 
semblage of  petty  contrivances  heaped  on  the  limb  by  Duver- 
ney.  All  these  expedients  act  only  on  the  inferior  portion  of 
the  femur,  yield  to  all  the  causes  that  move  it,  and  can  in  no 
manner  oppose  the  shortening  of  the  extremity. 

There  remains  another  method  which  demands  a  more  par- 
ticular notice.  It  was  proposed  by  Foubert,  adopted  by  Louis 
and  Citizen  Sabaticr,  and  approved  of  by  the  Academy  of  Sur- 
gery. This  method  was  for  some  time  looked  on  as  the  m.ost 
efFeftual  for  the  treatment  of  fractures  of  the  neck  of  the 
femur. 

The  frafture  being  set  according  to  the  rules  prescribed,  and 
compresses,  impregnated  with  a  resolvent  liquid,  applied  to  the 
articulation ;  the  thigh  and  leg  are  fixed  by  means  of  fanonsy 
and  the  foot  by  means  of  a  slipper  or  sole.  The  inferior  por- 
tion of  the  femur  is  in  a  very  short  time  drawn  outward  and  up- 
ward by  the  contraction  of  the  muscles.  This  derangement, 
foreseen  by  the  inventor  of  the  method,  is  remedied  by  reset- 
ting the  fraClure  every  day,  and  reapplying  the  apparatus.  From 
the  fifteenth  to  the  twentieth  day,  the  derangement  becomes 
less  frequent,  and  the  part  less  irritable;  for  which  reason  there 
is  less  muscular  contratStion.  After  the  twenty-fifth,  the  re- 
setting is  no  more  necessary,  the  limb  is  allowed  to  rest,  and  the 
fations  are  kept  employed,  tightening  them  as  often  as  they  re- 
lax, for  three  months  and  a  half,  at  which  time  the  apparatus 
may  be  totally  removed.  This  invention,  originally  suggested 
by  Ambrose  Pare,  does  not  merit  all  the  encomiums  whiqh 
have  been  bestowed  upon  it.  Nothing  can  more  effectually  re- 
tard, or  even  prevent  the  formation  of  the  callus,  than  the 
motions  communicated  to  the  limb,  at  the  very  time  that  na- 
.ture  is  most  actively  employed  in  generating  it. 

In  order  to  keep,  in  fractures  of  the  neck  of  the  femur,  the 
pieces  in  their  proper  situation,  it  is  necessary  that  some  cause 
counteracts  that  which  tends  to  produce  their  derangement. 
This  latter  aCts  by  drawing  upv.^.rd  -i^TA   outward  the  inferior 


I20  OF    FRACTURES    OF    THE    FEMUR. 

portion,  making  it  ascend  on  the  external  side  of  the  superior, 
which  is  itself  pushed  downward  by  the  weight  of  the  pelvis 
and  body.  A  further  derangement  is  produced  by  the  falling 
outward  of  the  foot  and  knee:  in  order  to  prevent  which,  it 
has  been  proposed  to  tie  the  toes  to  those  of  the  other  foot. 
Brunninghausen  used  to  fix  the  leg  of  the  fradlured  side  to  that 
of  the  opposite,  by  means  of  a  sort  of  stirrup,  making,  by  this 
contrivance,  the  sound  leg  aft  as  a  splint;  but  these  means 
serve  merely  to  prevent  the  falling  outward  of  the  foot,  but 
not  at  all  the  shortening  of  the  limb.  Besides,  the  position 
cannot  be  long  persevered  in,  because  fastening  both  legs  to- 
gether, incommodes  the  patient  very  much. 

A  continued  extension  is  the  only  means  of  keeping  down 
the  lower  portion  of  the  femur,  of  opposing  the  descent  of  the 
superior,  of  counteracting  the  irritability  of  the  muscles,  and  of 
producing  a  cure  without  lameness  or  deformity.  We  do  not 
propose,  as  already  remarked  in  the  first  chapter  of  this  work, 
to  overcome,  by  this  means  the  strong  and  involuntary  con- 
tractions of  the  muscles  which  immediately  succeed  the  frac- 
ture, and  which  should  be  opposed  by  a  moderate  and  gradual 
extending  force.  Tiie  application  of  the  apparatus  for  making 
continued  extension  is  not  prudent,  until  the  spasmodic  state 
be  completely  removed.  It  is  not  intended  that  this  apparatus 
shall  preternaturally  extend  the  muscular  fibre,  by  drawing  its 
extremities  in  opposite  direcSlions,  but  merely  that  it  shall  sup- 
ply the  place  of  the  bone,  by  opposing  the  contraclile  power 
naturally  inherent  in  the  fibre,  and  always  tending  to  act. 

Almost  all  those  who  have  acknowledged  the  indispensable 
necessity  of  continued  extension,  have  invented  different  means 
for  putting  it  into  execution.  Their  respective  merits  can  be 
appreciated  by  comparing  their  different  ways  of  acting  with 
the  general  rules  already  laid  down  for  effefting  this  purpose. 

The  bed  of  Hippocrates,  and  the  Glossocomon  used  by  the 
ancients,  engraved  in  the  Works  of  Pare,  have  been  abandon- 
ed on  account  of  their  complication:  they  had  no  other  advan- 
tage than  that  of  adting  in  the  direction  of  the  fractured  bone. 
By  acting  immediately  on  the  fractured  thigh,  in  effecting  ex- 
tension and  counter-extension,  their  acStion  was  limited  to  a 
small  surface,  and  the  limb  lengthened  abruptly. 

The  method  used  by  Avicenna,  adopted  by  Petit,  Heister, 
and  Duverncy*,  who  have  somewhat  modified  it,  consisted  in 

*  The  greater  part  of  authors  recommend  the  use  of  the  spica,  in  addi- 
tion to  the  extension  and  counter-excension  produced  by  ih:^  means. 


I 


OF    FRACTURES    OF   THE    FEMUR.  121 

fastening  to  the  head  and  foot  of  the  bed,  the  bands  with 
which  the  extension  and  counter-extension  were  to  be  efFedted. 
The  superior  were  applied  on  the  upper  part  of  the  thigh,  and 
the  inferior  above  the  knee. 

Petit  advises  to  place  two  bands  at  the  same  time,  one  above 
the  knee  and  another  above  the  ankle,  to  aft  alternately,  so 
that  when  one  becomes  troublesome  it  may  be  relaxed  and  the 
other  used. 

Besides  the  unsteadiness  of  the  band  placed  above  the  knee, 
and  the  irritation  of  the  muscles  occasioned  by  it;  this  method 
has  still  further  the  disadvantage  of  the  thigh  and  pelvis  not 
being  so  fixed  by  it  as  to  constitute  one  piece;  without  which 
essential  condition,  the  superior  portion  of  the  femur  yields  to 
all  the  motions  of  the  pelvis,  with  which  it  is  connefted.  The 
loosening  of  the  bands,  which  is  frequent  in  proportion  to  their 
length,  is  another  objection  which  decides  the  absolute  insuffi- 
ciency of  this  method.  In  confirmation  of  this  opinion,  we 
may  quote  the  testimony  of  the  Arabians  themselves,  invent- 
ors of  this  method,  who  used  it  in  every  case  of  fra£ture  of 
the  femur,  whatever  might  be  its  direftion,  but  who  acknow- 
ledge that  the  cure  was  seldom  effe£led  without  a  lameness. 

Others  have  endeavoured  to  the  efFeft  extension,  by  means 
of  a  band  applied  above  the  ankle,  and  which,  passed  over  a 
pully,  had  a  weight  suspended  from  the  other  extremity.  The 
puUy  was  so  disposed,  as  that  the  weight  adled  in  the  direftion 
of  the  fraftured  bone,  which  joined  to  the  advantage  of  afting 
on  the  leg,  produced  a  well  diredled  extension:  this,  however, 
was  rendered  useless  on  account  of  there  being  no  counter-ex- 
tension, to  prevent  the  body  from  being  drawn  downwards. 

The  machine  of  Bellocq,  described  and  engraved  in  the 
third  volume  of  the  Memoirs  of  the  Academy  of  Surgery,  is 
at  present  generally  abandoned.  By  it,  extension  is  made  in 
the  direiSlion  of  the  limb,  on  the  lower  part  of  the  leg,  and 
gradually;  but  the  counter-extension  adls  immediately  on  the 
superior  part  of  the  thigh:  besides,  the  great  difficulty  of  ap- 
plying this  machine,  justifies  the  oblivion  into  which  it  has 
fallen.  Many  other  apparatus  successively  proposed  after  that 
of  Bellocq,  and  of  which  they  were  but  modifications,  have, 
like  their  model,  fallen  into  dis-use. 

The  machine  of  Hook,  perfedted  by  Aitken,  and  described 
by  Bell,  afts  in  the  direction  of  the  limb,  and  produces  a  slow 
and  gradual  extension,  by  means  of  screws,  but  it  has  the  dis- 
advantage of  adling  immediately  on  the  inferior  part  of  the 
16 


122  OF    FRACTURES    OF    THE    FEMUR. 

thigh,  und  on  a  small  surface.  Thus,  while  two  precepts  are 
observed,  two  others  not  less  important  are  neglefted:  besides, 
nothing  opposes  the  falling  outward  of  the  foot  and  knee,  nor 
the  inclination  of  the  hip  to  the  same  side. 

Desault  perceived  all  these  imperfections  and  defedts,  and 
invented  an  apparatus  by  which  the  obje<5l  proposed  is  more 
perfedtly  fittained,  and  by  means  much  simpler.  It  might  be 
added  perhaps,  that  with  a  few  modifications,  it  would  com- 
prise every  advantage  that  can  be  expected  from  such  an  appa- 
ratus. His  first  attempts  were  directed  only  to  corredl  the  an- 
cient methods.  He  attached  the  trunk  to  the  head-board  of 
the  bed,  by  means  of  long  bands  fastened  to  a  bandage  passed 
under  the  arm  pits:  he  applied,  in  the  next  place,  the  middle 
of  a  band  on  some  thick  compresses  placed  on  the  back  part 
of  the  leg,  a  little  above  the  ankles;  the  extremities  of  this 
band  crossed  on  the  superior  part  of  the  foot,  and  knotted  on 
the  sole,  were  then  fastened  to  the  foot  of  the  bed.  To  this 
disposition  was  joined  the  ordinary  means  or  apparatus.  This 
method  had  a  disadvantage  of  which  we  have  already  taken 
notice,  namely,  the  facility  with  which  the  bands  relax;  be- 
sides which,  the  immobihty  of  the  body  was  very  fatiguing, 
and  the  difficulty  of  breathing,  on  account  of  the  bandage 
round  the  trunk,  was  still  more  distressing.  This  last  menti- 
oned disadvantage  induced  Desault,  in  a  particular  case,*  to 
apply  the  bandage  on  the  pelvis,  to  which  it  was  fixed  by 
bands  passed  under  the  thighs. 

Desault  ascertained  by  different  experiments,  that  the  ob- 
jedt  particularly  to  be  aimed  at,  and  which  was  essential,  was 
such  a  disposition  as  that  the  foot,  leg,  thigh,  and  pelvis, 
should  constitute  but  one  whole;  so  that,  though  the  different 
parts  thereof  should  be  drawn  in  different  directions,  yet  they 
should  still,  with  respedt  to  one  another,  preserve  the  same 
mutual  relation.  Convinced  of  the  justness  of  this  conclusion, 
he  invented  the  following  apparatus  to  answer  these  purposes. 

A  strong  splint,  long  enough  to  extend  from  the  ridge  of 
the  OS  ilium  to  a  certain  length  beyond  the  sole  of  the  foot, 
is  a  principal  part  of  this  apparatus:  this  splint  should  be  two 
inches  and  a  quarter  broad,  and  have  each  of  its  extremities 
pierced  in  shape  of  a  mortice,  and  terminated  by  a  semicircu- 
lar niche.  It  is  applied  on  the  exterior  side  of  the  thigh,  by 
means  of  two  strong  linen  bands,  each  being  more  than  a  yard 
long. 

*  Surgical  Journal,  vol.  i. 


OF    FRACTURES    OF    THE    FEMUR,  1 23 

The  middle  part  of  one  of  these  bands  is  to  be  applied  to 
the  inside  of  the  thigh,  at  its  upper  part;  its  ends  are  brought 
to  the  exterior  side  of  the  thigh,  passed  through  the  mortice, 
and  knotted  on  the  semicircular  niche.  Compresses  are  to  be 
previously  placed  under  the  middle  part  of  the  band,  in  order 
to  prevent  any  disagreeable  pressure;  as  well  as  on  the  tubero- 
sity of  the  ischium,  which  Desault  considered  as  the  principal 
point  of  adlion  of  this  band.  The  inferior  part  of  the  leg  is, 
in  the  next  place,  covered  with  compresses,  on  which  the  mid- 
dle part  of  the  second  band  is  placed:  the  extremities  of  this 
band  are  crossed  on  the  instep  and  upper  part  of  the  foot,  then 
on  the  sole,  after  which  they  are  conveyed  outward,  and  one 
end  passed  through  the  mortice  and  knotted  with  the  other  on 
the  niche,  with  such  a  degree  of  force  as  to  pull  the  inferior 
portion  of  the  femur  downward,  and  to  push  the  splint  up- 
ward, and  by  this  means  the  pelvis  and  superior  fractured  por- 
tion. On  the  internal  side  of  the  limb  is  placed  a  second 
splint,  which  extends  from  the  superior  part  of  the  thigh,  to 
a  certain  distance  beyond  the  foot.  A  third  is  placed  on  the 
anterior  part,  and  extends  from  the  abdomen  to  the  knee. 
The  superior  extremities  of  the  anterior  and  exterior  splints 
are  fixed  by  means  of  a  bandage  passed  round  the  pelvis.  A 
band,  the  middle  part  of  which  is  placed  under  the  sole  of 
the  foot,  and  the  extremities  crossed  on  its  superior  surface 
and  fastened  to  the  splints,  prevents  the  motion  of  the  foot, 
as  does  also  to  a  considerable  degree  the  action  of  the  splints. 

It  may  not  be  superfluous,  perhaps,  to  remark,  that  previ- 
ous to  the  application  of  this  apparatus,  the  whole  limb  should 
be  covered  with  compresses,  moistened  with  a  solution  of  the 
acetate  of  lead,  and  that  Scultet's  bandage  is  to  be  applied  on 
the  thigh  and  leg  over  these  compresses,  and  a  roller  to  be 
passed  round  the  foot :  these  parts  of  the  apparatus  should  be 
moistened  with  a  resolvent  liquid.  These  have  the  double  ad- 
vantage of  diminishing  the  irritability  of  the  muscles,  and  pre- 
venting any  stagnation  of  the  fluids. 

This  apparatus  of  Desault's  has,  in  the  hands  of  that  cele- 
brated surgeon  produced  a  great  number  of  cures;  but  it  must 
at  the  same  time  be  acknowledged  that  it  has  frequently  failed: 
the  causes  of  failure  may  be  found  in  defeats  which  it  is  easy 
to  point  out. 

The  superior  band  has  a  triple  disadvantage;  first,  that  of 
forcing  the  inferior  portion  of  the  femur  outward;  secondly,  of 
pushing  the  superior  upward;    thirdly,  of  rolling  itself  into  a 


124  OF    FRACTURES    OF    THE    FEMUR. 

cord,  compressing  thereby  painfully  the  adduftor  and  re£lus  in- 
ternus,  the  spasmodic  contradlion,  of  which,  in  consequence  of 
the  pressure,  tends  still  further  to  produce  the  ascent  of  the 
inferior  portion  of  the  femur.  These  disadvantages  would  be 
all  removed,  by  giving  the  band  a  point  d'appui  on  the  tuberosi- 
ty of  the  ischium. 

The  difficulty,  however,  of  afling  on  a  globular  eminence 
of  a  small  surface,  and  covered  by  a  great  depth  of  soft  parts, 
is  easily  seen:  the  extension  of  the  thigh  on  the  pelvis  increases 
this  difficulty,  by  increasing  the  depth  of  the  soft  parts.  This 
tuberosity  would  be  more  prominent  for  the  inverse  reason, 
if,  according  to  Pott's  method,  the  limb  were  placed  in  the 
half-bent  position.  The  difficulty  of  adling  on  this  tuberosity 
is  much  greater  in  women  than  in  men,  on  account  of  the 
greater  quantity  of  cellular  substance  about  this  part  in  females. 
Not  only  is  it  difficult  to  make  the  band  a6l  on  that  tuberosity, 
but  other  disadvantages  result  from  it;  for  the  great  pressure 
of  the  band  on  these  delicate  parts,  causes  much  pain,  ulcera- 
tion, and  sometimes  gangrene.  To  these  circumstances  De- 
sault  attributed  the  ill  success  which  he  sometimes  met  with. 

The  inferior  band  has  nearly  the  same  disadvantages  as  the 
superior;  its  dire<flion  is  oblique  downward  and  outward,  and 
its  action  tends  therefore  to  produce  a  derangement  of  the 
pieces  of  bones.  This  tendency  is  counteradted,  it  is  true,  by 
the  band  diredled  to  be  applied  to  the  back  part  of  the  leg 
above  the  ankle,  crossed  on  the  superior  and  inferior  surfaces 
of  the  foot,  and  fastened  to  the  lower  extremities  of  the  in- 
ternal and  external  splints.  The  compresses  with  which  the 
inferior  part  of  the  leg  is  covered,  do  not  always  proteft  it 
from  the  extreme  constriftion  of  the  lower  band^  which  being 
narrow,  forms  itself  quickly  into  an  hard  cord,  and  causes 
pain  by  adling  on  a  narrow  surface.  The  gangrenous  eschars, 
which  are  sometimes  produced  by  the  constriction  of  this  band- 
age, are  so  considerable,  as  to  denude  in  many  cases  the  ten- 
do  Achillis,  and  the  tendons  of  the  extensor  muscles  of  the 
toes.  These  tendons,  exposed  to  the  contact  of  the  air,  arc 
apt  to  exfoliate,  and  consequently  the  bones  which  they  are 
destined  to  move  will  remain  motionless.  The  oblique  adlion 
of  this  band  renders  a  great  constriction  necessary. 

If,  in  order  to  appreciate  exadlly  the  merit  of  this  method, 
we  compare  its  manner  of  acting  with  the  general  rules  alrea- 
dy laid  down  for  effecting  perpetual  extension,  we  shall  find 
that  some  of  these  rules  are  transgressed,  and  others  not  com- 


OF    FRACTURES    OF    THE    FEMUR.  1^5 

pletely  observed.  Thus  the  extending  force  a£ts  on  that  part 
of  the  limb  which  articulates  with  the  inferior  fra(^ured  por- 
tion; but  the  superior  band  adts  on  the  superior  fractured  por- 
tion; and  the  bands  being  narrow  and  liable  to  roll  up  like  a 
cord,  do  not  aft  on  large  surfaces.  Both  the  inferior  and  su- 
perior bands  being  oblique,  they  cannot  a£t  in  the  direction  of 
the  bone.  Finally,  their  a6tion  cannot  be  gradually  increased. 
The  method  of  Citizen  Boyer,  which  remains  to  be  described, 
is  striiSlly  conformable  to  all  these  rules.  By  his  apparatus  and 
method,  the  extension  is  gradual  and  in  the  dire<Stion  of  the 
bone;  and  none  of  the  muscles  which  surround  the  fractured 
bone  are  compressed. 

The  apparatus  consists  of  a  splint,  a  sole,  or  slipper,  and  a 
sous-cuisse.  The  splint  should  be  four  feet  long,  three  fingers 
breadth  wide,  and  about  four  or  five  lines  in  thickness,  and 
made  of  hard  and  inflexible  wood.  A  groove  about  half  an 
inch  wide,  the  extremity  of  which  is  covered  with  iron,  runs 
along  this  splint  for  about  half  its  length.  In  this  groove  is 
placed  a  screw  which  occupies  its  whole  length,  one  end  of  it 
being  supported  against  the  plate  of  iron  with  which  the  ex- 
tremity of  the  groove  is  covered,  the  other  being  adapted  to  a 
key  by  which  it  is  turned.  To  this  screw  is  fastened,  in  the 
manner  shewn  in  the  plate,  an  apparatus  to  which  the  sole  is 
fixed.  The  superior  part  of  the  splint  is  received  into  a  pocket 
formed  in  the  sous-cuisse.  The  sole  is  made  of  iron,  and  co- 
vered vyith  shammy  leather;  towards  the  heel  a  large  piece  of 
soft  leather  is  attached  to  it,  which  piece  is  divided  into  two, 
and  serves  to  fix  the  sole  to  the  foot.  It  is  fixed  to  the  part 
of  the  apparatus  connefted  with  the  screw. 

The  sous-cuisse  is  composed  of  two  parts,  which  meet  at  an 
acute  angle.  It  is  made  of  strong  leather,  covered  with  sham- 
my and  well  stuffed  with  wool,  like  the  girdle  of  a  truss;  one 
of  the  parts  should  be  long  enough  to  pass  obliquely  round 
the  upper  part  of  the  thigh,  its  extremity  terminating  in  a 
strap  pierced  with  holes:  the  other  should  be  only  three  inch- 
es long,  and  terminated  by  a  buckle.  At  the  place  where  both 
parts  meet,  a  piece  of  leather  is  sewed  in  form  of  a  pocket, 
into  which  the  superior  part  of  the  splint  is  received. 

It  is  difficult  to  give  a  satisfaftory  explanation  of  all  the  par- 
ticular parts  of  which  this  apparatus  is  composed;  but  a  suffi- 
ciently correal  idea  of  it  may  be  formed  by  taking  a  view  of 
the  plate  No.  2. 


126  OF    FRACTURES    OF    THE    FEMUR. 

The  apparatus  is  applied  in  the  following  manner:  after  ha- 
ving surrounded  the  upper  part  of  the  thigh  with  a  soft  gir- 
dle of  cotton  three  inches  broad,  the  sous-cuisse  is  applied  over 
it.  Then  the  foot  and  lower  part  of  the  leg  is  surrounded 
with  some  soft  matter,  in  order  to  secure  against  the  effefts  of 
pressure,  and  the  sole  is  applied  to  the  foot.  Next  the  superi- 
or part  of  the  splint  is  introduced  into  the  pocket  of  the  sous~ 
cuisse^  and  the  sole  is  attached  at  the  proper  place  to  the  re- 
mainder of  the  apparatus. 

The  application  being  thus  far  advanced,  the  necessary  stuff- 
ing and  two  splints,  one  anteriorly,  the  other  internally,  are 
applied  and  secured  in  the  ordinary  manner.  Every  thing  be- 
ing thus  disposed,  the  screw  in  the  groove  is  turned  by  the 
key,  and  the  sole  descends  and  brings  the  foot  with  it,  whilst 
the  superior  part  of  the  splint  is  pushed  upwards.  In  this 
way  the  limb  may  be  extended  gradually,  and  the  extension 
increased  as  may  be  necessary. 

Which  ever  apparatus  is  adopted,  it  will  be  necessary  to  exa- 
mine it  frequently,  to  tighten  the  bands,  which  are  quickly 
relaxed  in  Desault's  apparatus,  and  to  give  a  few  turns  to  the 
screw  in  that  of  Boyer;  but  for  the  latter,  not  near  so  much 
attention  is  necessary:  the  straps  of  skin  by  which  the  exten- 
sion and  counter-extension  are  made,  though  over  extended 
by  any  accidental  cause,  return  again  t^  the  proper  degree  of 
constriction,  on  account  of  their  elasticity;  and  though  they 
should  become  relaxed,  the  means  of  bracing  them  are  easy. 
When  Desault's  apparatus  is  used,  it  will  be  necessary  to  in- 
crease the  thickness  of  the  compresses  on  the  back  part  of  the 
leg,  the  tuberosity  of  the  ischium,  and  inside  of  the  thigh,  as 
soon  as  these  parts  begin  to  excoriate. 

Topical  applications,  except  those  necessary  for  combating 
the  inflammatory  symptoms,  are  absolutely  useless.  If  there 
be  contusion  and  violent  inflammation,  the  removal  of  these 
must  precede  the  application  of  any  apparatus.  The  bed  on 
which  the  patient  is  laid,  should  not,  as  already  mentioned,  be 
too  soft,  but  ought  to  be,  on  the  contrary,  firm  enough  to 
prevent  his  sinking  into  it.  By  adopting  Desault's  method,  or 
that  of  Boyer,  the  patient  may  satisfy  his  natural  wants  with- 
out inconvenience. 

The  general  rule  of  confining  the  patient  to  a  low  regimen 
should  be  modified  in  the  present  case;  because  in  this,  more 
than  in  any  other,  it  is  necessary  to  support  and  increase  the 
vital  action  of  the  parts.    A  rigourous  abstinence,  which  would 


OF    FRACTURES    OF    THE    FEMUR.  127 

in  other  cases  only  retard  the  formation  of  callus,  might  to- 
tally prevent  it  in  this.  Therefore,  though  the  quantity 
of  nourishment  should  be  less  than  that  used  in  a  state  of 
perfedt  health,  because  the  exercise  taken  in  that  state  ren- 
ders reparation  more  necessary,  yet  any  abstinence  that  might 
induce  debility  should  be  avoided. 

Does  the  difficulty  with  which  fractures  of  the  neck  of  the 
femur  consolidate,  authorize  the  use  of  internal  remedies,  which 
might  accelerate  the  consolidation? 

The  ancients  wei*e  of  opinion  that  in  a  few  days  after  a  frac- 
ture the  patient  should  be  nourished  with  rich  gelatinous  food. 
Andre  de  la  Croix,*  and  Fabricius  ab  Aquapendente,  pre- 
scribe formally,  in  imitation  of  Galen,f  the  use  of  farinaceous 
and  young  animal  food,  and  that  of  inspissating  medicines. 
Ambrose  Pare:};  has  given  the  same  directions,  and  observed 
them  himself  in  the  treatment  of  the  fradhire  of  his  leg.  Fa- 
bricius Hildanus§  remarks  with  reason,  that  aliments  of  this 
kind  are  diflicult  of  digestion,  and  m.ust  therefore  be  very  un- 
fit for  a  patient  in  a  state  of  inaClivity.  But  the  same  objection 
lies  against  the  use  of  csteocolla,  recommended  by  the  same 
praiftitioner,  and  condemned  by  Van  Swieten,||  on  the  same 
principle  as  the  inspissating  or  viscid  aliments  of  Galen,  Osteo- 
colla,  so  highly  recommended  by  Fabricius,  has  been  used  by 
the  greater  number  of  sui'geons.  Some  cases  are  found  in  the 
Philosophical  Transactions,**  in  which  the  production  of  a  part 
of  the  femur  is  attributed  to  the  use  of  it ;  but  Citizen  Pinel, 
translator  of  this  work,  judiciously  remarks,  that  it  is  difficult  to 
conceive  how  a  stone  of  a  calcareous  nature,  and  of  the  melac- 
tite  species,  could  aid  the  generation  of  callus.  The  use  of 
gelatinous  food  which  came  into  use  on  the  supposition  of  its 
being  of  a  nature  analogous  to  the  supposed  osseous  fluid,  has 
been  discontinued;  and  the  theory  on  v/hich  it  was  founded, 
has  been  abandoned.     Spirituous  liquors,  recommended   to- 

•  Dum  substantia  cartilaginea,  compafta  ac  densa,  quam  Latini  callum 
vocant,  gigniiurj  eo  tempore  viscosum  alimer.tuin  commeiidatur.  An- 
tlieasa  Cruce,  vol.  ii.  lib.  i,  cap.  6,  de  Cibo. 

f  De  Methodo,  lib.  6,  cap.  5. 

X  Lib.  15,  cap.  28. 

§  Surgical  Observations,  Cent.  1.   Obs.  92. 

II  Comment,  on  Hermann  Boeih,  Aph. 

•*   Abridgment  of  th«  Phil.  Trans.— Med.  and  Surg. 


128  OF    FRACTURES    OF    THE    FEMUR. 

ward  the  end  of  the  treatment,  for  the  purpose  of  hardening 
the  caUus,  have,  in  like  manner,  fallen  into  disuse. 

Nourishment  easy  to  digest,  and  the  moderate  use  of  spirit- 
uaus  drinks,  particularly  for  old  people,  aid  that  expansion  of 
the  vascular  texture,  necessarv  for  the  generation  of  callus.  A 
scrupulous  attention  should  be  paid  to  the  manner  of  living, 
when  the  vital  forces  are  found  to  languish  from  any  cause 
whatever. 

The  time  which  nature  employs  for  the  consolidation  of  a 
fradlure  of  the  neck  of  the  femur,*  has  already  been  men- 
tioned. We  repeat  however,  that  the  apparatus  should  not  be 
finally  removed  before  the  sixteenth  or  seventeenth  day;  and 
that  three  months  must  elapse  from  the  day  of  the  fracture  to 
that  on  which  the  patient  may  be  safely  allowed  to  quit  his  bed, 
and  walk  even  with  the  aid  of  crutches.  The  premature  use  of 
the  limb  has  been  more  than  once  the  occasion  of  its  being 
shortened,  after  the  formation  of  the  callus  had  been  conside- 
rably advanced,  and  a  cure  without  blemish  on  the  point  of 
being  efFecled.  A  shortening  of  the  limb  is  particularly  to  be 
apprehended,  if  the  pieces  are  united  by  meany-of  a  ligamento- 
cartilaginous  substance.  That  the  premature  use  of  the  limb 
may  occasion  this  unfortunate  accident  may  be  easily  conceived, 
by  refledling  that  the  callus  does  not  attain  its  ultimate  degree 
of  consistence  until  after  the  lapse  of  several  months. 

A  stiffness  in  the  articulation  is  not  much  to  be  apprehended, 
though  some  instances  of  it  are  related  by  authors;  these  exam- 
ples would  be  more  numerous,  if  the  stiffness  were  produced  by 
an  effusion  of  osseous  juice  into  the  articulation,  as  some  au- 
thors have  thought.  It  is  well  known  at  present  that  this 
stiffness  or  false  anchylosis  is  owing  to  the  impeded  circulation 
in  the  part,  and  to  the  muscles  having  lost  the  habit  of  motion 
by  a  long  inactivity.  Fractures  of  the  patella  and  olecranon  are 
more  frequently  than  any  others  attended  with  this  conse- 
quence. 

To  this  description  of  the  treatment  of  fradlures  of  the  neck 
of  the  femur,  we  have  only  to  add,  that  cases  occur  in  which 
the  approved  method  cannot  be  adopted.  I  have  often  seen 
patients  who  could  not  support  the  pain  produced  by  it.  In 
which  case,  or  in  that  of  the  patient's  being  old,  the  continued 
extension  ought  not  to  be  persisted  in :  the  apparatus  for  frac- 

*  The  consolidation  was  always  effected  from  the  foity-fifth  to  the  fif- 
tieth day,  according  to  the  cases  related  in  the  Surgical  Journal. 


OF    FRACTURES    OF    THE    PATELLA.  l<ig 

tures  of  the  body  of  the  bone  must  be  had  recourse  to,  with 
the  additional  precaution  of  guarding  against  the  rotatory  de- 
rangement, by  making  the  internal  and  external  splints  extend 
beyond  the  foot.  A  cure  thus  obtained,  will  be  attended  with 
a  shortening  of  the  limb. 

If  the  patient  were  abandoned  to  nature,  the  continual  mo- 
tion which  would  take  place,  and  the  friftion,  would  destroy 
the  head  of  the  bone,  and  often  too  what  remains  of  the  neck, 
as  has  been  observed  by  Morgagni.  The  shortening  is  so  great 
in  that  case,  that  the  limb  is  nearly  useless.  Boehmer  has  ju- 
diciously remarked,  in  his  Osteologic  Institutions,  that  the  de- 
ficiency alone  of  a  point  d'appui  would  cause  lameness,  though 
the  member  should  have  lost  no  part  of  its  length. 


CHAPTER  XV. 


OF  FRACTURES  OF  THE  PATELLA. 


THESE  fractures  may  be  transverse,  or  of  different  de- 
grees of  obliquity;  but  are  seldom  found  longitudinal. 
The  transverse  fra£lure  is  frequently  occasioned  by  a  sudden 
and  violent  contraction  of  the  extensor  muscles  of  the  leg, 
which  a£t  on  the  patella:  this  cause  remained  a  long  time  un- 
noticed, and  the  fractures  produced  by  it  were  ascribed  to  the 
fall  which  was  the  consequence  of  the  fradlure.  It  is  at  pre- 
sent generally  acknowledged  to  be  the  immediate  cause  of  the 
fracture,  and  by  that  means  the  cause  of  the  fall. 

It  will  be  asked,  perhaps,  why  the  tendon  of  the  extensors 
of  the  leg,  and  the  inferior  ligament  of  the  patella,  are  not 
ruptured  rather  than  the  patella  itself.''  To  which  it  may  be 
answered,  that  the  extensibility  of  the  tendinous  and  ligamen- 
tous parts  renders  them  less  liable  to  be  ruptured  than  the  pa- 
17 


130  OF    FRACTURES    OF    THE    PATELLA. 

tella,  the  hardness  of  which  is  more  than  compensated  by  itar 
brittleness  as  an  osseous  substance. 

Though  fracSture  of  the  patella  is  the  most  frequent  conse- 
quence of  a  violent  contracStion  of  the  extensors,  yet  a  rupture 
of  their  tendon  and  the  inferior  ligament  is  sometimes  pro- 
duced by  the  same  cause.  In  both  cases  the  symptoms,  prog- 
nosis, and  indications,  are  the  same  j  and  the  treatment  is  per- 
fe<^ly  identical. 

To  form  a  correal  idea  of  the  manner  in  which  fraftures  of 
the  patella  take  place,  it  is  necessary  to  recollect,  that  the  ere£t 
posture  is  the  firmest  possible,  when  the  centre  of  gravity  is  in 
a  line  perpendicular  to  the  basis  on  which  the  body  is  support- 
ed; that  though  the  line  passing  through  the  centre  of  gravity 
may  cease  to  be  perpendicular,  yet  the  body  does  not  fall,  but 
is  kept  ere6l  by  the  action  of  muscles,  which  counterajfls  the 
deviation  from  the  perpendicular  dire<^ion:  finally,  that  if  this 
line  fall  on  no  part  of  the  base,  the  body  must  necessarily  fall 
towards  that  side  to  which  the  line  inclin-es. 

If  the  centre  of  gravity  fall  behind  the  base,  so  that  the 
body  tends  backwards,  the  extensor  muscles  of  the  leg  contrail 
with  great  violence,  in  order  to  prevent  the  flexion  of  the 
thighs,  at  the  same  time  that  the  superior  part  of  the  body  i& 
also  drawn  forward  by  the  contraiStion  of  muscles,  and  the  cen- 
tre of  gravity  replaced  on  its  natural  support.  If  this  contrac- 
tion of  the  muscles  be  not  sufficient  to  bring  the  body  forward, 
the  obliquity  of  the  axis  of  the  centre  of  gravity  still  increa- 
sing, the  adtfon  of  the  muscles  will  increase  in  consequence;  so 
that  the  patella  pushed  forward  by  the  inferior  extremity  of 
the  femur,  drawn  with  great  force  by  the  tendon  of  the  triceps 
and  re6lus  anterior,  and  retained  in  the  opposite  direction  by 
the  inferior  ligament,  is  fradlured  transversely. 

The  effort  made  to  resist  falling  is  not  the  only  occasion  on 
which  the  patella  is  violently  acted  on  by  an  instantaneous  con- 
traction of  the  muscles  inserted  into  it.  It  is  exposed  to  the 
effects  of  a  violent  contraction  of  the  muscles  in  leaping,  which 
as  performed  by  the  human  species,  consists  principally  in  the 
sudden  extension  of  the  low*^r  extremities,  which  are  always 
bent  to  the  leap:  for  which  reason  a  fraCture  of  the  patella  of- 
ten occurs  in  dancers,  and  always  takes  place  the  instant  of  their 
quitting  the  ground.  Another  circumstance  in  which  a  trans- 
verse fra<Sture  of  the  patella  may  take  place,  is  that  in  which, 
the  point  of  the  foot  is  forcibly  impelled  forward;  an  instance, 
of  which  is  found  in  the  case  of  a  soldier,  who  made  an  atf 


OF  FRACTURES  OF  THE  PATELLA.       I3I 

tempt  to  kick  his  sergeant.  In  this  case,  the  manner  in  which 
the  fracture  takes  place  is  analogous  to  that  of  the  olecranon, 
produced  by  the  a£lion  of  throwing  a  stone.  Another  case  of 
this  fracture  is  that  of  a  man  brought  to  La  CbaritCy  in  the 
month  of  Pluvio'se,  8th  year.  This  person  was  a  coachman; 
his  horses  took  fright  while  he  sat  negligently  on  the  box;  on 
which  occasion  he  extended  suddenly  the  right  leg,  at  the  same 
moment  that  the  point  of  the  right  foot  slipped  off  the  board 
on  which  it  rested.  He  felt  instantly  a  very  acute  pain  in  the 
knee,  and  heard  very  distinctly,  at  the  same  time,  a  loud  crack; 
and,  on  applying  his  hand  to  the  part,  he  found  the  patella 
fractured  transversely,  and  divided  into  two  pieces,  which  were 
separated  an  inch  one  from  the  other.  These  instances  remove 
every  doubt  on  the  possibihty  of  this  fracture  being  effected  by 
muscular  action  alone  ;  and  if  any  further  evidence  were  neces- 
sary, it  would  be  found  in  a  case  of  a  fracture  of  this  nature, 
which  took  place  by  the  violent  contractions  of  the  mucles  of 
the  thigh  of  a  man  in  convulsions. 

Falling  on  the  knees  is  a  no  less  frequent  cause  of  transverse 
fracture  of  the  patella:  in  this  case  it  takes  place  easily  when 
this  bon€,  made  to  project  by  the  flexion  of  the  leg,  strikes 
against  some  very  hard,  resisting  body.  When  the  leg  is  bent, 
the  patella  is  supported  only  by  its  extremities  on  the  superior 
end  of  the  tibia,  and  the  articular  part  of  the  femur,  so  that  its 
middle  part  is  without  any  support,  and  corresponds  with  the 
interval  between  the  two  last-mentioned  bones  :  this  space  is 
occupied  by  the  adipose  cellular  texture  found  behind  the  infe- 
rior ligament  of  the  patella.  In  this  situation  of  the  parts,  the 
patella  is  easily  fractured,  because  the  middle  part  of  it,  which 
is  unsupported,  is  the  thinnest,  and  because  it  is  steadily  fixed  by 
the  action  of  the  tendon  and  ligament  which  are  inserted  into  it. 
The  direction  of  the  fradture  depends  generally  on  the  shape  of 
the  body  against  which  the  knee  strikes.  Should,  for  instance, 
its  projecting  part  be  transverse  to  the  patella,  the  fraClure  will 
have  the  same  direftion  ;  if  longitudinal  the  fracture  will  be 
longitudinal,  &c.  The  same  may  be  said  of  the  violent  impul- 
sion of  a  body  against  the  patella.  In  all  cases  this  bone  may 
be  broken  into  several  pieces,  and  the  soft  parts  lacerated  ;  or 
the  fradlure  may  be  complicated  with  a  rupture  of  the  capsular 
ligament,  and  an  effusion  of  blood  into  the  articulation. 

Transverse  fractures  of  the  patella  are  always  attended  with 
a  separation  of  the  fraftured  portions.  When  the  cause  of 
fraaure  has  been  just  sufficient  to  produce  the  solution  of  con- 
tinuity of  the  bone,  without  disorganizing  its  fibrous  covering. 


1^2  OF    FRACTURES    OF    THE    PATELLA. 

the  derangement  is  at  first  scarcely  perceptible ;  but  this  mem- 
brane stretches  in  a  Uttle  time.  The  shghtest  motions  of  the 
leg  are  sufEcient  for  elongating,  or  even  totally  rupturing  this 
substance :  in  which  case  the  separation  becomes  instantly 
considerable,  and  the  articulation,  from  being  no  longer  sup- 
ported, bends  under  the  weight  of  the  body.  The  following 
case  is  a  remarkable  instance  of  a  fradlure,  in  which  the  sepa- 
ration of  the  pieces,  and  the  fall  which  is  the  inevitable  conse- 
quence of  it,  did  not  immediately  follow  the  solution  of  con- 
tinuity. The  person  while  dancing,  heard  a  dull  noise  in  the 
right  knee,  and  felt  a  slight  pain  in  the  same  part.  Some  mi- 
nutes after  in  walking  about  the  room,  he  heard  another  crack 
in  the  same  knee,  and  fell  without  the  power  of  raising  himself. 
On  being  brought  to  La  Charlie  the  portions  of  the  patella  were 
found  separated  an  inch  and  three  fourths,  which  with  the  other 
signs,  left  no  doubt  on  the  existence  of  fradlure.  An  uniting 
bandage,  such  as  is  generally  made  use  of  for  simple  incised 
wounds,  was  applied,  and  renewed  as  often  as  its  relaxation 
rendered  it  necessary.  On  the  thirtieth  day  of  the  treatment^ 
the  knee  was  gently  moved,  in  order  to  prevent  a  false  anchy- 
losis, and  the  motion  was  afterwards  continued  every  day  until 
the  patient  quitted  the  hospital.  An  interval  of  about  one  line 
in  breadth  separated  the  two  pieces,  which  was  entirely  filled 
up  by  a  ligamentous  substance,  of  a  very  inextensible  nature. 

Two  causes  concur  to  produce  the  separation  of  the  frac- 
tured portions;  one  of  which  is,  the  contraction  of  the  exten- 
sor muscles,  which  always  takes  place  when  their  natural  ten- 
dency to  contradt  is  not  opposed,  and  by  which  the  superior 
portion  is  drawn  upward  on  the  superior  part  of  the  thigh:  the 
second  cause  is  the  flexion  of  the  leg,  the  principal  bone  of 
which  draws  downward  the  inferior  piece  which  is  attached  to 
it.  The  separation  will  be,  then,  great  in  proportion  to  the 
force  of  muscular  contraftion,  the  degree  of  flexion  of  the  leg 
on  the  thigh,  and  the  extension  or  laceration,  more  or  less  of  the 
tendinous  expansion  which  covers  the  anterior  surface  of  the  pa- 
tella, and  which  is  attached  to  the  lateral  parts  of  that  bone,  and 
adheres  strongly  at  the  same  time,  to  the  capsular  ligament. 

Nothing  can  be  easier  than  the  diagnosis  of  fractures  of  the 
patella.  If  this  bone  be  fractured  transversely,  by  a  forced  ex- 
tension of  the  leg,  the  patient  falls,  and  remains  without  the 
power  of  rising.  The  fall  may  instantly -succeed  the  fraflure, 
or  there  may  be  some  interval.  The  impossibility  of  rising  ex- 
ists also  when  the  fradure  is  efiedted  by  a  fall  on  the  knee.    If 


OF    FRACTURES    OF    THE    PATELLA.  I33 

raised  by  the  aid  of  others,  the  patient  falls  again  If  he  attempts 
to  advance;  he  can,  however,  move  backward,  by  drawing  the 
soles  of  his  feet  along  on  the  ground,  and  by  taking  care  not 
to  bend  the  knee. 

A  boy  fell  on  the  ice  the  1 1th  Nivose,  year  8,  and  fra£lured 
transversely  the  patella  of  the  right  side:  his  efforts  to  rise  were 
to  no  purpose;  he  was  therefore  obliged  to  make  his  way  on  his 
back  to  a  neighbouring  house,  sixty  paces  distant.  He  was 
there  put  on  his  feet,  and,  by  leaning  on  another  person,  was 
able  to  walk  backward  three  hundred  paces  to  the  place  of  his 
destination,  from  which  he  was  conveyed  to  La  Charite.  On 
the  12th  a  slight  degree  of  swelling  manifested  itself  about  the 
articulation;  to  reduce  which,  and  to  calm  the  pain  which  was 
very  acute,  emollient  poultices  were  applied.  The  Inflammatory 
symptoms  entirely  disappeared  on  the  eighth  day  after  the  acci- 
dent, at  which  time  the  usual  apparatus  was  applied.  Toward 
the  conclusion  of  the  treatment,  the  articulation  was  exercised 
gradually  every  day:  the  patient  quitted  the  hospital  In  the  be- 
ginning of  Ventose,  having  the  portions  of  the  patella  united 
by  a  ligamentous  substance,  half  an  inch  broad.  The  great 
strength  of  this  ligamentous  substance  rendered  the  joint  of  the 
knee  sufficiently  strong,  though  it  was  a  little  stiff  on  the  pa- 
tient's quitting  the  hospital. 

Besides  the  signs  resulting  from  the  cause  and  circumstances 
of  a  fracture  of  the  patella,  there  are  others  still  equally  easy 
to  be  ascertained,  and  not  less  conclusive.  A  depression  is 
found  on  the  anterior  part  of  the  knee.  Instead  of  the  promi- 
nence naturally  formed  by  the  patella  at  that  part :  the  two 
fractured  portions,  which  are  more  or  less  separated  one  from 
the  other,  may  be  made  to  approach  by  extending  the  leg  on 
the  thigh,  and  bending  the  thigh  on  the  pelvis;  and  they  may 
be  moved  laterally  in  opposite  clire6tions:  a  crepitation  may  be 
very  easily  produced,  on  account  of  the  slight  covering  of  soft 
parts.  A  case  may  occur  however,  in  which  the  separation  of 
the  fractured  portions  cannot  be  distinguished,  as  when  there  Is 
a  great  Inflammatory  swelling  about  the  knee;  but  this  uncer- 
tainty is  of  no  importance;  because,  even  were  the  frafture 
ascertained,  nothing  could  be  done  to  bring  the  divided  por- 
tions together,  until  the  Inflammation  had  abated. 

Is  the  consolidation  of  a  frafture  of  the  patella  analogous 
to  that  of  other  bones?  or  is  the  process  of  nature  different  In 
this  case  from  what  It  Is  In  all  others?  Some  authors  have 
been  of  opinion  that  the  fraiSlured  portions  of  this  bone  are 


\ 


134  OF    FRACTURES    OF    THE    PATELLA. 

susceptible  of  an  immediate  reunion,  by  being  placed  in  con- 
ta£^;  but  the  greater  number  question  the  possibility  of  such 
a  reunion;  and  assert,  on  the  contrary,  that  the  pieces  are  al- 
ways united  by  means  of  a  ligamentous  substance,  which  is 
long,  thin,  and  very  extensible,  when  the  fradture  has  not  been 
well  treated;  but  which  is,  on  the  contrary,  short,  thick,  and 
unyielding,  when  the  treatment  has  been  well  diredled. 

Camper  is  the  principal  author  of  the  latter  theory,  which 
he  supports  by  a  great  number  of  cases.  The  Academy  of 
Surgery  adopted  it  on  the  evidence  of  similar  fafts;  and  it  is 
now  brought  forward  in  a  Treatise  on  Surgery,*  lately  publish- 
ed in  the  north :  we  do  not  hesitate  to  subscribe  to  it. 

Those  who  maintain  that  the  consolidation  of  a  fradlure  of 
the  patella  is  analagous  to  that  of  fractures  of  other  bones,  ap- 
peal to  experience,  and  cite  numerous  instances  of  an  immedi- 
ate reunion,  which  they  attribute  to  a  more  perfect  mode  of 
treatment.  But  as  this  pretended  immediate  reunion  has  not 
been  attested  by  disse£tion  of  the  part  after  death,  it  is  possi- 
ble that  a  very  close  connexion,  by  means  of  a  ligamentous 
substance,  scarcely  perceptible  to  the  touch  through  the  inte- 
guments, may  have  been  taken  for  an  immediate  union.  A 
postillion  received  a  kick  from  a  horse  the  8th  Messidor,  year 
6,  which  fractured  the  patella  of  the  left  knee,  near  its  infe- 
rior angle:  the  fibrous  expansion  prevented  the  separation  of 
the  pieces  for  some  time.  The  inflammatory  symptoms  not 
being  intense,  yielded  quickly  to  the  usual  antiphlogistic  treat- 
ment: the  uniting  bandage  was  applied,  and  the  knee  gradu- 
ally moved  as  soon  as  the  progress  of  the  cure  allowed  it  to  be 
done  with  safety.  The  patient  quitted  the  hospital  on  the  18th 
Thermidor,  perfectly  recovered:  and  so  small  was  the  interval 
between  the  two  pieces,  that,  without  a  very  attentive  exami- 
nation, it  might  be  supposed  that  there  was  none.  But  had 
they  who  supported  the  theory  of  the  union  by  a  ligamentous 
substance,  contented  themselves  with  opposing  their  adversa- 
ries by  fa£ts,  the  question  could  not  have  remained  long  unde- 
cided. They  attempted  to  explain  the  faft;  and  their  adver- 
saries,   by  being  able    easily  to    overthrow   their  reasoning, 

*  "  Patella  frafla,  baud  uti  alia  corporis  humani  ossa,  verb  callo  concres- 
cit,  sed  fragmenta,  solum  mcdiaiite  substantia  finnioie,  cellulosa,  cartilagi- 
nosa,  cum  ligamento  mucoso  concurrente,  conglutinantur,  er  fiirtijori  cica- 
trisatione  ligamentorum  continentur,  quod  oonstans  experient'a,  in  vivis 
et  cadavarihus,  nos  edocuit." — Callisen,  Pnncipia  Systemacis  Chir, 
Hod.     §  ?288. 


OF    FRACTURES    OF    THE    PATELLA^  I3J 

thought  that  they  had  thereby  proved  that  the  fa<fi:  never  oc- 
curred, as  if  a  bad  explanation  could  invalidate  a  well  attested 
faa. 

We  have  already  shewn  that  the  explanation  of  the  non- 
consolidation  of  fractures,  founded  on  the  want  of  a  perioste- 
um and  lubrification  of  the  fraclured  surfaces  by  the  synovia, 
is  vague. 

Some  authors,  supposing  that  the  patella  was  differently  or- 
ganized from  other  bones,  have  endeavoured  to  explain,  from 
this  difference  of  stru6lure,  the  peculiarities  of  the  consolida- 
tion of  its  fradlures.  But  it  does  not  differ  in  its  organization 
from  the  other  small  bones  of  the  body,  among  which  it  is 
classed  by  the  greater  number  of  anatomists.  Like  them,  it  is 
composed  principally  of  a  spongy  texture,  covered  by  a  very 
thin  layer  of  compacft  substance.  The  fibres  of  the  patella, 
when  perfeftly  ossified,  are  visibly  the  continuation  of  those  of 
the  tendon,  in  the  midst  of  which  it  is  formed.  This  diredtion  or 
continuation  of  fibres  is  easily  demonstrated  by  the  action  of  ni- 
tric acid  on  the  patella,  the  calcareous  part  of  which  it  dissolves. 
The  consolidation  of  fracflured  bones  is  effeiSled  by  the  same 
process  as  the  cicatrization  of  wounds  of  soft  parts;  that  is,  by  a 
turgescence  and  expansion  of  the  vascular  texture  of  the  part: 
hence,  the  less  dense,  and  the  more  specifically  light  any  bone 
is,  the  greater  is  the  number  of  vessels  which  pass  through  it, 
and  the  less  is  the  proportion  of  its  saline  parts  to  its  volume; 
and  further,  the  more  intimate  and  multiplied  are  its  points  of 
contact  with  the  neighbouring  soft  parts,  so  much  the  more  ener- 
getic is  its  vital  aftion,  and  the  more  rapid  its  consolidation 
when  fradhared.  The  fractured  surfaces  of  the  patella,  on 
which  a  great  number  of  vessels  are  distributed,  are,  for  the 
foregoing  reasons,  much  disposed  to  the  inflammatory  turges- 
cence, so  necessary  for  the  union  of  divided  parts;  and  the 
consolidation  would  be  very  prompt  if  the  granulations  could 
be  brought  into  immediate  contact,  and  if  mechanical  causes 
did  not  countera^l:  the  consolidating  process. 

According  to  Callisen,  the  adipose  cellular  texture  placed 
behind  the  inferior  ligament  of  the  patella,  presses  itself  be- 
tween the  divided  portions  of  that  bone,  and  prevents  their 
immediate  reunion.  When  the  leg  is  fully  extended,  the  in- 
ferior ligament  of  the  patella  is  also  in  a  state  of  tension,  and 
the  cartilaginous  trochlea  of  the  condyles  of  the  femur  leaves 
no  vacuum  behind  the  patella:  in  which  disposition  of  the 
parts,  says  Callisen,   this  cellular  substance  is  forced  upv/axd 


13^  OF    FRACTURES    OF    THE    PATELLA. 

and  forward,  and  thrust  between  the  pieces  of  bone,  so  as  to 
prevent  their  conta6l  and  immediate  reunion:  but  in  no  case  is 
this  cellular  substance  placed  between  the  patella  and  anterior 
part  of  the  condyles  of  the  femur;  and  even  though  it  should 
be  placed  there,  and  should  insinuate  itself  between  the  frac- 
tured portions,  yet  it  could  not  prevent  their  immediate  reuni- 
on, if  it  ^'ere  possible  to  keep  them  in  contact  by  a  proper 
apparatus. 

The  impossibility  of  doing  so  is  the  sole  obstacle  to  the  im- 
mediate reunion  of  the  fradtured  portions;  and  the  cause  of 
this  impossibility  is  found  in  the  contractility  of  the  extensor 
muscles,  which  cannot  be  directly  opposed  by  any  bandage. 
For  were  it  attempted  to  press  down  the  superior  portion,  and 
confine  it  in  its  place  by  a  bandage,  it  is  plain  that  this  means 
could  only  adt  perpendicularly  to  the  muscles  which  tend  to 
draw  it  upward,  and  cannot  therefore  be  completely  efFedtual ; 
there  remains,  consequently,  a  greater  or  less  interval  between 
the  two  portions  of  bone,  the  fibrous  covering  of  which  be- 
comes turgid  and  inflamed  from  the  tension  and  irritation,  and 
insinuates  itself  into  the  interval,  so  as  to  fill  it  up  entirely. 
Such,  in  our  opinion,  is  the  cause  and  mode  of  formation  of 
this  ligamentous  substance. 

The  strength,  thickness,  and  inextensibility  of  this  sub- 
stance, is  in  an  inverse  proportion  with  its  length.  When 
long,  it  is  thin,  -weak,  and  extensible,  and  transmits  but  im- 
perfe<Stly  the  adlion  of  the  extensor  muscles  to  the  leg.  When 
short,  on  the  contrary,  it  is  thick,  strong,  and  unyielding,  and 
does  not  perceptibly  diminish  the  aftion  of  the  muscles,  nof 
impede  the  motion  of  the  articulation. 

The  diminution  of  muscular  adlion  is  not  the  sole  disadvan- 
tage resulting  from  the  length  of  this  ligamentous  substance; 
the  strength  of  the  knee,  the  flexion  of  which  is  naturally 
graduated  by  the  patella,  is  also  diminished  by  it;  for  the  low- 
er extremity  of  the  femur  having  no  longer  its  natural  support 
and  resistance,  the  flexion  is  sudden  and  abrupt:  hence  per- 
sons so  a£fe6led  fall  from  the  slightest  cause.  Galen*  relates 
the  case  of  a  wrestler,  whose  patella  ascended  on  the  anterior 
part  of  the  thigh,  in  consequence  of  the  rupture  of  its  inferior 
ligament.  Every  flexion  of  the  knee  put  this  person  in  the 
most  imminent  danger  of  falling.  Descending  a  declivity  was 
painful  to  him,  and  he  wife  always  obliged  to  use  a  stick  on 

*  De  Usu  Partiiim,  lib.  iii.  cap.  15. 


OF    FRACTURES    OF    THE    PATELLA.  IJ7 

Such  occasions.  Ambrose  Pare*  informs  us,  that  those  who 
have  had  the  patella  fraiHured  have  much  difficulty  in  ascend- 
ing a  rising  ground,  but  that  they  can  walk  with  ease  in 
an  horizontal  direflion.  Duverneyf  mentions  the  case  of 
a  young  man,  whose  patella  was  raised  above  the  condyles 
of  the  femur,  and  fixed  there,  in  consequence  of  the  rupture 
of  its  inferior  ligament.  This  person  could  not  walk  up  stairs, 
but  could  readily  come  down.  Morgagni|  mentions  a  great 
number  of  similar  fafts.  I  might  add  several  others,  all  con- 
curring to  prove,  that,  when  the  knee  has  lost  the  support  of 
the  patella,  walking  on  rugged  uneven  ground  is  very  difficult, 
and  ascending  a  steep  place  almost  impossible. 

From  what  has  preceded,  it  appears  that  the  great  objecl  to 
be  attended  to  in  the  treatment  of  fra(Stures  of  the  patella,  is 
the  diminution  of  the  interval  between  the  pieces,  in  order 
that  the  ligamentous  substance,  which  is  necessarily  generated, 
may  be  as  short  and  strong  as  possible.  Previous  to  the  appli- 
cation of  the  apparatus,  means  are  to  be  used  to  prevent  the 
accession  of  inflammation*,  or,  if  it  has  taken  place,  every  ef- 
fort is  to  be  made  to  remove  it.  As  inflammation  does  not  in- 
stantly succeed  the  fradlure,  its  approach  may  be  sometmies  en- 
tirely prevented.  The  most  efficacious  remedies  in  such  case 
are  fomentations  with  a  solution  of  acetate  of  lead,  and  parti- 
cularly cold  applications,  such  as  pounded  ice,  or  very  cold 
water.  These  remedies  are  particularly  applicable  before  the 
accession  of  the  inflammatory  symptoms.  When  the  inflam- 
mation supervenes,  the  afflux  of  humours  to  the  part,  which 
the  irritation  tends  to  produce,  is  to  be  opposed,  and  the  return 
of  these  humours  into  the  circulation  favoured.  Do  we  not 
find,  that  in  plunging  into  a  bath  at  the  freezing  point,  any 
part  which  has  been  exposed  to  the  action  of  an  irritating 
cause,  as,  for  instance,  the  immediate  adlion  of  fire,  or  any 
injury  which  excites  inflammation,  is  rendered  in  some  degree 
torpid,  or  has  its  sensibility  diminished.''  Which  diminution  of 
sensibility  is  a  mark  of  a  partial  suspension  of  the  vital  proper- 
ty of  th6  part,  and  is  accompanied  with  a  great  diminution  of 
the  pain.  The  principle  of  irritability  resides  in  the  nerves, 
they  being  the  sole  organs  of  sensibility.  By  a  momentary 
extindlion  of  that  property,  or  by  a  considerable  diminution  of 

*  OEuvres  d'Ambroise  Pare,  b.  xv-cap.  zi. 

■j-  Treatise  on  the  Diseases  of  the  Bones,  vol  i. 

X  De  Scdibus  &  Causis  Morboruin,  Epiit.  56,  No.  27, 

IS 


IjS  OF    FRACTURES    OF    THE    PATELLA. 

it,  do  we  not  i\^£l  aj^?inst  the  cause  of  the  evil,  rather  than 
against  its  effects?  Whatever  may  be  the  value  of  this  reason- 
ing, experience  teaches  us,  tliat  in  the  case  in  question,  and  in 
all  similar  cases,  the  immersion  of  the  part  in  cold  water  is 
useful,  and  should  be  continued  for  several  hours,  the  water 
being  frequently  reviewed,  in  order  to  keep  up  the  cold.  If 
the  s\n-geon  has  not  arrived  in  time  to  have  recourse  to  this 
means,  or  if  the  contusion  be  so  violent  as  to  render  inflamma- 
tion inevitable,  the  general  antiphlogistic  treatment  is  to  be 
pursued,  and  adapted  to  the  age,  strength,  temperament,  &c. 
of  the  patient.  The  pain  is  alleviated,  and  the  tension  dimi- 
nished, by  extending  the  leg.  Bell  recommends  the  applica- 
tion of  a  great  number  of  leeches  to  the  part;  but  it  appears  to 
us  that  this  cannot  be  done  with  safety  in  the  greater  number 
of  .cases;  for  the  irritation  produced  by  their  bites,  added  to 
that  already  existing,  might  bring  on  gangrene  of  the  part, 
and  the  patient's  death.  In  most  cases,  as  when  the  fradlure 
is  a  consequence  of  a  fall  on  the  knee,  the  inflammation  is  in- 
considerable, and  disappears  in  a  few  days;  then  compresses, 
wet  with  a  solution  of  acetate  of  lead,  may  be  placed  on  the 
part,  and  the  apparatus  may  be  applied  over  them. 

If  the  contusion  be  excessive,  and  blood  be  effused  into  the 
articulation  through  its  lacerated  capsule,  as  well  as  into  the 
cellular  texture,  the  inflammatory  symptoms  will  be  violent, 
then  an  antiphlogistic  regimen  and  copious  blood-letting  must 
be  had  recourse  to;  and  should  a  suppuration  take  place,  not- 
withstanding our  endeavours,  incisions  should  be  made,  in  or- 
der to  give  a  free  issue  to  the  purulent  matter.  This  treat- 
ment is  sometimes  successful,  but  at  other  times,  notwithstand- 
ing every  precaution,  the  patient  is  cut  off".  Such  was  the  fate 
of  a  mason,  brought  to  La  Char'ite^  whose  patella  had  been 
crushed  rather  than  fraiStured  by  the  fall  of  a  large  stone.  If 
the  contusion  be  not  confined  to  the  anterior  part  of  the  knee, 
the  leg  should  not  be  fully  extended,  but  placed  rather  half 
bent,  that  being  the  position  in  which  all  the  soft  parts  are 
equally  relaxed.  This  position  produces,  it  is  true,  a  separa- 
tion of  the  divided  portions  of  bone;  but  the  treatment  must 
be  in  the  first  instance  directed  against  the  inflammatory  symp- 
toms rather  than  against  the  fracture.  If  the  inflammation  be 
not  subdued  before  the  twentieth  or  twenty-fifth  day,  it  will 
be  useless  to  apply  the  apparatus ;  because  the  ligamentous  sub- 
stance is  already  formed,  and  has  acquired  a  tolerable  consist- 
ence: its  length  is  much  greater  than  it  would  be,  were  it  pos- 


OF    FRACTURES   OF   THE    PATELLA.  ,13^ 

sible  to  apply  the  apparatus,  and  the  strength  of  the  knee  is 
considerably  diminished.  The  patient  is  doomed  to  the  disad- 
vantage already  mentioned,  of  not  being  able  to  walk  on  an 
uneven  surface  but  with  great  difficult)'',  nor  to  ascend  a  rising- 
place  without  some  artificial  support.  When  the  Inflamniato- 
ry  symptoms  are  subdued  in  this  case,  all  that  remains  to  be 
done  is  to  guard  against  a  false  anchylosis,  by  gradually  moving 
the  leg  from  the  moment  that  it  can  be  done  with  safety,  un- 
til the  motion  is  free,  and  not  attended  with  pain. 

The  condudl  to  be  pursued  when  the  inflammation  has  been 
overcome  in  time  to  admit  of  the  application  of  the  apparatus, 
or  when  it  was  originally  trifling,  has  been  already  pointed  outj 
we  shall,  however,  recapitulate  the  particulars:  the  leg  is  to  be 
extended  on  the  thigh,  and  the  thigh  is  to  be  bent  on  the  pel- 
vis. The  limb  is  to  be  supported  in  this  position  by  means  of 
pillows,  or  some  such  bodies,  placed  under  it  from  the  buttock 
to  the  heel,  and  means  are  to  be  used  to  keep  the  fractured 
portions  in  contact. 

Some  authors  have  been  of  opinion  that  this  position  was 
alone  suflicient,  and  that  all  apparatus  for  confining  the  pieces 
are  useless.  This  is  the  opinion  of  Valentin  and  Citizen  Saba- 
tier,  who  relates  in  the  Memoirs  of  the  Academy  of  Surgery, 
1783,  several  cases  of  fractures  of  the  patella  cured  by  this 
position  alone.  But  it  must  be  observed,  with  all  due  de- 
ference to  the  opinion  of  these  practitioners,  that  as  no  mea- 
sure is  taken  to  secure  against  the  motion  of  the  limb 
or  the  irritability  of  the  muscles,  which  tend  incessantly  to 
draw  the  superior  fradtured  portion  upwards,  there  is  every 
probability  that  the  interval  between  the  pieces  of  bone  will  be 
considerable.  Besides  the  ligament  which  fills  up  this  interval 
will  be  still  further  lengthened,  and  therefore  weakened,  by 
the  incautious  motions  of  the  limb;  or  it  may  be  broken  be- 
fore it  has  acquired  its  full  consistence.  This  will  inevitably 
be  the  case  if  the  patient,  frcyTi  any  cause,  bend  the  knee  for- 
cibly: such  an  accident  would  necessarily  retard  the  cure,  or 
totally  prevent  it,  if  frequently  repeated. 

The  bandage  in  the  form  of  the  figure  8,  and  composed  of 
a  band  rolled  up  from  both  ends,  the  two  globes  of  which  are 
made  to  cross  one  another  alternately  in  the  ham,  and  to  em- 
brace both  sides  of  the  patella,  causes  a  congestion  of  the  foot 
and  leg,  by  not  compressing  the  whole  limb.  Besides,  the  ac- 
tion of  this  bandage  is  oblique,  and  much  of  it  is  spent  in 
merely  compressing  the  neighbouring  soft  parts,  which  it  irri- 


J40  OF    FRACTURES    OF    THE    PATELLA. 

|:ates,  and  sometimes  excoriates;  neither  is  this  inconvenlenc*; 
remedied  by  the  pasteboard  trough,  and  compresses  propose4 
by  Louis  as  an  addition  to  this  bandage.  The  part  of  its  action 
which  is  employed  on  the  fradlured  parts  is  always  insufficient 
to  keep  them  in  contaft,  if  the  constriction  be  not  greater  than 
the  patient  can  bear  for  any  length  of  time.  If,  in  order  to 
avoid  this  disadvantage,  the  bandage  be  not  drawn  sufficiently 
tight,  its  objedt  will  be  entirely  frustrated,  and  its  application 
useless.  These  defedts,  occasioned  this  bandage  to  be  re- 
jected, and  led  to  the  invention  of  another  much  less  objec- 
tionable. 

A  bandage,  which,  instead  of  occasioning  an  oedematous 
swelling  of  the  limb,  obviates  it  by  making  an  equable  pressure 
on  all  its  parts,  which  adts  in  diredt  opposition  to  the  muscles, 
which  tend  to  separate  the  portions  of  bone,  and  which,  by 
acting  on  these  muscles,  diminishes  their  irritability  and  en- 
feebles their  action,  must  concur  powerfully  with  a  good  posi- 
tion to  efFeCt  a  favourable  union  of  the  divided  portions  of  the 
patella.  The  uniting  bandage  used  for  transverse  wounds  pos- 
sesses all  these  advantages,  when  modified  as  we  shall  present- 
ly mention.  The  relaxed  state  into  which  the  parts  are  put 
by  the  extension  of  the  leg  on  the  thigh,  and  the  flexion  of 
the  thigh  on  the  pelvis,  favours  its  a6tion. 

In  applying  this  bandage,  one  assistant  fixes  the  pelvis, 
while  another  raises  and  supports  the  whole  inferior  extremity. 
The  surgeon  takes  a  strip  of  linen  longer  than  the  whole  limb, 
and  broader  than  the  patella,  extends  it  on  the  inferior  part  of 
the  leg,  and  fixes  it  by  several  turns  of  a  roller;  he  then  turns  up 
the  inferior  extremity  of  the  piece  of  linen,  over  which  he  again 
winds  the  roller,  which  he  continues  to  apply  as  far  as  the  articu- 
lation of  the  knee.  He  then  commits  the  roller  to  an  assistant, 
while  he  himself  extends  the  skin  over  the  patella,  lest  it  should 
sink  or  be  thrust  in  between  the  pieces  of  bone,  which  he  brings 
into  as  close  contact  as  possible,  and  includes  them  in  two  long 
compresses  passed  obliquely  round  them,  and  crossed  in  the 
ham.  In  the  next  place  he  extends  the  longitudinal  piece  of 
linen  first  mentioned  on  the  knee  and  thigh,  as  before  on  the 
leg,  and  again  takes  the  roller,  which  he  carries  obliquely  over 
the  compresses,  observing  at  the  same  time  to  let  the  folds 
cross  one  another  in  the  ham.  The  application  of  this  roller 
is  continued  upward  on  the  thigh,  and  by  its  means  the  longi- 
tudinal piece  of  linen  is  fixed  nearly  as  far  up  as  the  groin, 
from  which  its  superior  extremity  is  turned  downward,  having 


OF    FRACTURES   OF    THE    PATELLA;  I4I 

been  previously  drawn  upward  with  much  force.  The  roller 
is  again  carried  downward  over  this  double  strip,  and  continu- 
ed over  the  knee  and  leg  until  it  is  entirely  applied.  Another 
roller  is  passed  several  times  on  the  foot,  and  the  whole  com- 
pleted by  applying  a  long  splint  on  the  back  part  of  the  limb 
from  the  buttock  to  the  heel.  This  splint  is  kept  applied  by 
means  of  several  turns  of  a  bandage  passed  round  it,  and  the 
pressure  made  by  it  may  be  prevented  from  being  inconvenient 
by  placing  a  long  cushion  of  chafF  between  it  and  the  limb.  By 
this  means  the  patient  is  prevented  from  bending  his  leg,  which, 
without  this  precaution,  he  would  probably  do,  and  thus  frus- 
trate all  our  efforts.  The  pain  arising  from  the  constriction 
and  continued  extension  renders  it  impossible  for  the  patient  to 
keep  the  limb  extended  without  the  assistance  of  a  splint. 

This  apparatus  preserves  the  pieces  of  bone  exactly  in  their 
place  in  the  comrhencement;  but  as  the  circumference  of  the 
limb  quickly  diminishes,  the  rollers  become  relaxed  ;  the  mus- 
cles which  were  adted  on  perpendicularly,  are  no  longer  suffi- 
ciently compressed  j  they  therefore  draw  upwards  the  superior 
jjortion.  But  this  separation  will  be  very  inconsiderable,  if  the 
patient  be  frequently  visited,  and  the  rollers  tightened  as  often 
as  they  are  found  loose. 

This  chapter  might  be  much  extended,  by  drawing  from  the 
profound  oblivion  in  which  they  are  buried  the  numerous  ap- 
paratus invented  at  different  and  distant  times  for  the  treatment 
of  fraftures  of  the  patella.  Some  advantage  might,  however, 
be  derived  from  the  use  of  some  of  them,  such  as  the  pieces 
of  metal,  leather,  or  pasteboard,  with  an  opening  in  the  mid- 
dle for  the  reception  of  the  patella.  Or  for  these  apparatus 
might  be  substituted  two  pieces  of  metal,  covered  so  as  to  em- 
brace the  patella.  The  concave  sides  of  these  metallic  pieces 
might  be  covered  with  hair,  in  order  to  diminish  the  pressure 
on  the  soft  parts.  This  apparatus  does  not  exclude  the  appli- 
cation of  the  splint  and  rollers,  &c. 

These  general  principles  of  treatment  being  once  established, 
nothing  can  be  easier  than  to  apply  them  to  particular  cases. 

We  shall  describe  another  apparatus,  which  appears  to  us 
very  capable  of  keeping  the  leg  extended,  and  the  portions  of 
bone  in  the  greatest  possible  state  of  approximation.  This 
consists  of  a  trough,  long  enough  to  extend  from  the  superior 
part  of  the  thigh  to  the  s.uall  of  the  leg,  and  wide  enough  to 
receive  the  thigh  and  leg.  Small  buttons  are  fixed  to  the  edges 
of  this  trough,  to  which  may  be  attached  two  straps,  that  cross 


142  OF    FRACTURES    OF    THE    PATELLA. 

one  another,  and  are  fastened  in  the  following  manner.  The 
trough  being  lined  with  carded  cotton  or  soft  linen  rags,  the 
limb  is  placed  in  it  in  such  a  manner  as  that  the  calf  of  the  leg 
shall  correspond  to  its  middle  part:  it  is  then  fixed  in  that  situ- 
ation by  means  of  a  circular  bandage.  One  of  the  leather 
straps  is  then  fixed  to  one  of  the  inferior  buttons,  which  rises 
vertically  from  the  external  edge  or  border  of  the  trough,  and 
conveyed  upward  and  inward,  and  fastened  to  one  of  the  supe- 
rior buttons  of  the  internal  side.  The  other  strap  is  fixed  .in 
the  same  way  from  the  inside  outward,  so  that  they  cross  one 
another  at  their  middle  part,  and  embrace  the  superior  frac- 
tured portion  in  their  ■  inferior  angle.  It  will  be  necessary  to 
extend  the  skin  over  the  patella  before  the  straps  are  tightened. 
Compresses  soaked  in  a  resolvent  liquid  are  then  applied,  and 
a  few  turns  of  the  remaining  part  of  the  roller  are  passed  round 
the  whole.  The  extremities  of  the  straps  should  be  made  of 
leather,  but  the  middle  parts  of  buffalo-skin  stuffed  with  hair 
like  a  bandage  for  a  herni<«,  in  order  to  guard  against  any  ex- 
coriation of  the  parts  on  which  they  press.  The  simple  me- 
chanism of  this  apparatus  may  be  more  perfe^ly  comprehended 
by  means  of  the  engraving,  Plate  3,  fig.  1  and  2. 

Some  authors  have  been  of  opinion  that  the  separation  of 
the  fractured  portions,  so  far  from  injuring  the  motions  of  the 
knee,  was,  on  the  contrary,  favourable  to  these  motions;  and 
have  in  consequence,  proscribed  every  species  of  bandage  which 
could  prevent  that  separation.  These  authors  content  them- 
selves with  simply  moving  the  limb  after  the  disappearance  of 
the  inflammatory  symptoms,  in  order  to  guard  against  a  false 
anchylosis.  They  allow  the  limb  to  remain  in  the  half-bent  posi- 
tion. But  a  stiffness  in  the  articulation  of  the  knee  is  a  conse- 
quence much  less  to  be  dreaded  than  the  weakness  and  disabi- 
lity which  necessarily  result  from  the  length  of  the  intermedi- 
ate ligamentous  substance :  for  which  reason  this  method  has 
but  very  few  partisans.  It  is  applicable  only  in  cases  of  a  longi- 
tudinal fradlure  of  the  patella,  which  very  seldom  happens, 
and  in  which  the  pieces  remain  naturally  in  conta<n:.  An  anchy- 
losis may  be  always  guarded  against  with  certainty,  by  begin- 
ning to  move  the  articulation  about  the  twenty-fifth  day.  If  the 
treatment  has  been  judicious  and  regular,  no  danger  can  re- 
sult from  gentle  motion  of  the  joint  at  that  period;  and  the 
extent  to  which  the  motion  is  carried  may  be  increased  every 
day  until  flexion  and  extension  can  be  performed  freely  and 
without  pain. 


f\ 


143 


CHAPTER  XVI. 


OF  FRACTURES  OF  THE  BONES  OF  THE  LEG. 


SECTION    I. 

Of  FraBures  of  the  Leg, 

THIS  name  is  given  to  frad\ures  of  the  leg  when  both  the 
bones  composing  it  are  broken;  and  such  fractures  are 
much  more  frequent  than  those  of  the  tibia  or  fibula  singly. 
The  middle  part  of  these  bones  is  that  which  is  generally  frac- 
tured; for  the  great  thickness  and  strength  of  the  superior  part 
of  the  tibia  render  fractures  at  that  part  very  rare;  but  the  in- 
ferior, not  being  equally  strong,  is  sometimes  fra^lured,  and 
with  it  the  fibula.  Both  bones  are  generally  fra^lured  at  the 
same  height :  this  is  a  necessary  consequence  of  the  simultane- 
ous a£lion  of  the  fracturing  cause. 

These  fraClures  may  be  transverse  or  oblique,  and  are  subjecSt 
to  every  species  of  derangement.  The  longitudinal  derange- 
ment is,  however,  much  less  common  than  the  horizontal  or 
angular.  In  the  former  case,  the  inferior  pieces  are  almost  al- 
ways drawn  outward  and  backward,  whilst  the  superior  proje<n: 
internally  and  forward.  The  angular  derangement  may  be  pro- 
duced either  by  the  action  of  the  posterior  muscles  of  the  leg  or 
the  weight  of  the  bodj'-,  and  in  either  case  the  angle  will  be 
salient  anteriorly.  The  salient  angle  may  take  place  posteriorly, 
if  the  heel  be  too  much  raised.  The  derangement  in  the  cir- 
''umference  arises  from  the  inclination  of  the  foot  inward  or 
outward,  but  it  most  commonly  fails  in  the  latter  direction. 
The  longitudinal  derangement  is  extrei^ely  rare,  and  cannot 


144  OF    FRACTURES    OF    THE    LEG. 

easily  take  place  in  transverse  fractures,  on  account  of  the  con-^ 
siderable  extent  of  the  fractured  surfaces;  but  in  oblique  frac- 
tures the  inferior  pieces  are  almost  always  drawn  upward  by  the 
adlion  of  the  posterior  muscles  of  the  leg,  in  which  position  of 
the  parts  the  lower  ends  of  the  superior  portions  project  anteri- 
orly, and  may  be  felt  by  the  hand.  Sometimes,  however, 
when  the  solution  of  continuity  is  obliquely  downward  and  out- 
ward, the  anterior  projection  will  be  produced  by  the  lower 
pieces.  In  some  cases  the  pointed  ends  of  the  bones  tear  and 
penetrate  the  integuments  in  both  kinds  of  derangement. 

Fradlure  of  the  leg  is  accompanied  by  all  the  signs  or  symp- 
toms mentioned  in  treating  of  fraflures  in  general  in  the  first 
chapter.  Change  of  direction  and  shape  of  the  limb,  pain,  and 
incapability  of  motion,  mobility  of  the  fractured  pieces,  and 
crepitation  always  distinct,  &c. — all  these  circumtances  render 
this  fraiSture  so  evident,  that  it  is  impossible  to  be  mistaken  re- 
specting its  existence. 

The  prognosis,  less  unfavourable  than  in  fradtures  of  the 
thigh,  varies  according  to  the  part  of  the  bone  fra£tured,  the 
direction  of  the  fraCture,  and  many  other  circumstances.  The 
fraCtures  which  take  place  near  the  knee  are  not  much  subjeCt 
to  derangement,  on  account  of  the  thickness  of  the  bone  in 
that  part ;  but  are  however,  more  dangerous  than  those  of  the 
middle  part,  as  being  subjeCtto  be  followed  by  a  stiffness  of  the 
knee  joint.  FraCtures  of  the  inferior  part  are  still  more  dan- 
gerous. Oblique  fraCtures  are  very  difficult  to  be  managed; 
and  when  their  derangement  is  upward  and  outward,  the  in- 
teguments are  very  apt  to  be  torn  by  the  projecting  points  of 
the  superior  portions  of  bone. 

As  to  the  treatment  of  a  simple  fraCture  of  the  leg,  the  pa- 
tient is  to  be  carefully  undressed  in  the  first  place,  and  then 
laid  on  a  hard  and  narrow  bed,  perfectly  horizontal,  and  with- 
out any  board  at  the  end.  Afterwards  the  apparatus  are  ar- 
ranged in  the  following  manner:  1,  three  pieces  of  tape,  or 
linen;  2,  a  square  piece  of  linen  cloth  longer  than  broad;  3,  a 
sufficient  number  of  short  pieces  of  linen  to  cover  the  whole 
leg,  or  Scultet's  bandage;  4,  two  quadrilateral  compresses;  5, 
three  cushions  of  oaten  chaff,  and  three  splints,  two  lateral^ 
long  enough  to  extend  from  the  knee  to  a  small  distance  be- 
yond the  sole  of  the  foot,  and  a  third  anterior  shorter  than  th^ 
leg.  All  the  pieces  of  the  apparatus  being  thus  disposed,  and 
the  compresses  and  short  bandages  being  wet  with  a  resolvent 
liquid,  an  assistant  takes  hold  of  the  knee  with  both  his  hands. 


OF    FRACTURES    OF    THE    LEO,  I45 

and  another  seizes  the  foot,  having  both  his  thumbs  applied  to 
its  sole:  while  both  pull  in  opposite  direiSlions,  the  surgeon  per- 
forms coaptation.  The  moment  that  the  bones  come  into  their 
right  situation  is  easily  known,  on  account  of  the  thin  covering 
of  the  tibia  anteriorly.  The  square  compresses  are  then  laid 
over  the  leg,  and  on  them  Scultet's  bandage,  commencing  al-  , 
ways  with  the  lowest  pieces.  The  lateral  splints,  in  the  next 
place,  rolled  up  in  the  square  linen  cloth,  are  applied  in  such 
a  manner  as  that  they  may  rest  perpendicularly  on  their  edges, 
nearly  in  contact  with  the  leg,  between  which  and  them  a  bag 
of  chaff  is  placed  on  each  side,  by  means  of  which  the  depres- 
sions of  the  leg  are  filled  up.  The  remaining  chaff-bag  is  placed 
on  the  anterior  part  of  the  leg  for  a  similar  purpose,  and  over 
it  the  third  splint.  An  assistant  holds  fast  with  both  his  hands 
the  different  pieces  thus  placed,  while  the  surgeon  secures  them 
more  permanently  by  means  of  the  three  linen  bands,  which  he 
knots  over  the  external  splint,  commencing  always  with  the 
middle  one.  The  apparatus  is  completed  by  securing  the  foot 
by  means  of  a  small  band  to  the  lateral  splints,  in  order  to  pre- 
vent it  from  falling  to  either  side.  But  as  the  foot  might  be 
forced  to  either  side  by  the  weight  of  the  bed-clothes,  this  in- 
convenience is  guarded  against  by  means  of  a  hojop  placed  per- 
pendicularly on  its  ends  over  the  leg.  If  the  patient's  stomach 
be  not  full  he  should  be  bled,  and  afterwards  confined  to  a  low 
regimen. 

Not  only  is  it  useless  to  place  compresses  under  the  heel,  as 
was  practised  by  the  ancients,  but  it  is  attended  with  manifest 
disadvantages.  The  heel  being  raised  by  these  compresses, 
supports  the  whole  weight  of  the  limb;  and  the  pressure  some- 
times occasions  gangrene,  to  such  a  degree,  that  the  os  calcis 
is  laid  bare.  Besides,  by  the  elevation  of  the  heel,  the  frac- 
tured part  of  the  leg  loses  its  support,  and  a  salient  angle  is 
produced  backward  by  the  weight  of  the  limb. 

A  roller  cannot  be  substituted  for  Scultet's  bandage,  but  in 
cases  of  children  under  two  years  of  age. 

If  on  the  day  after  the  application  of  the  apparatus,  the  foot 
be  neither  painful  nor  swelled,  and  a  slight  degree  of  oedema 
be  alone  perceptible  in  that  part,  the  apparatus  need  not  be 
removed.  It  will  be  necessary  to  tighten  the  external  bands 
every  day,  and  to  wet  the  whole  with  a  repellent  liquid;  and 
at  the  end  of  eight  days  the  apparatus  should  be  re-applied. 
Some  pra^itioners  do  not  change  the  first  dressing  for  eighteen 
or  twenty  days:  but  it  frequently  happens,  that  during  this 
19 


146  OF    FRACtURpS    OF    THE    LEG. 

time  the  fra^red  portions  become  deranged  in  the  direction  of^ 
the  diameter  or  axis  of  the  bone,  and  that  their  consolidation^ 
has  already  advanced  considerably  in  this  vicious  position.  This 
derangement  may  be  occasioned  by  some  accidental  or  involun- 
tary motions;  some  defeft  in  the  first  application  of  the  appara- 
tus, or  (what  is  of  the  greatest  importance)  by  the  bed  not  be- 
ing perfectly  horizontal.  The  pradlice  of  deferring  for  such  a 
length  of  time  the  re-applrcation  of  the  apparatus,  has  probably 
originated  from  the  use  of  the  circular  bandage  or  roller.  The 
motion  which  should  necessarily  be  given  to  the  limb  in  re-ap- 
plying that  bandage,  was  certainly  a  sufiicient  justification  of 
the  practice.  In  adopting  the  improved  method  which  we  have 
described,  the  whole  apparatus  should  be  re-applied  ever}'  seven 
days,  and  the  external  bands  tightened  whenever  the  relaxation 
may  render  it  necessary. 

On  the  fortieth  or  forty-fifth  day,  the  progress  of  consolida- 
tion may  be  examined ;  and  if  the  callus  be  found  solid,  the 
circular  bandage  or  roller  may  be  safely  substituted  for  that 
which  we  have  described,  and  the  patient  may  be.  allowed  to 
sit  up  and  take  any  convenient  posture,  and  in  a  very  short 
time  to  walk  about  with  the  aid  of  crutches.  The  stiflhess  of 
the  knee  and  instep  arising  from  the  long  ina6livity,  will  render 
walking  diflficult  for  some  time. 

For  the  three  or  four  first  days  the  patient  should  be  allowed 
only  broths,  which  may  be  gradually  changed  for  more  sub* 
stantial  food.  If  he  be  costive  during  his  confinement,  clysters 
may  be  administered;  and  should  other  incidental  symptoms 
occur,  they  are  to  be  combated  by  appropriate  remedies. 

We  shall  not  trouble  our  readers  by  treating  particularly  of 
compound  frafture  of  the  leg,  because  we  could  only  repeat 
what  we  have  already  very  minutely  detailed. 

When  the  leg  is  fradlured  very  obliquely,  continued  exten- 
sion ought  to  be  employed,  particularly  when  the  points  of  the 
fraftured  portions  penetrate  though  the  integuments.  In  cases 
of  this  nature,  in  which  there  is  some  hope  of  preserving  ths 
limb,  if  the  patient  be  strong  and  healthy,  some  blood  should 
be  taken  from  the  arm,  and  the- extending  apparatus  applied.. 


OF    FRACTURES    OF    THE    LEG.  I47 


SECTION  U. 


K)f  FraElures  of  the  Tibia. 

This  bone  bears  the  whole  weight  of  the  body  transmitted  to 
it  from  the  femur,  and  is  fradlured  on  that  account  more  fre- 
jqucntly  than  the  fibula,  though  it  is  much  thicker  and  stronger 
than  the  latter.  But  as  fractures  of  it  are  almost  always  trans- 
verse, they  are  not  very  dangerous. 

If  the  fracture  take  place  near  the  inferior  extremity,  the 
great  extent  of  the  fractured  surfaces  prevents  any  considerable 
derangement  of  the  fraftured  portions;  and  the  fibula  acting  as 
^  support  on  the  external  sides,  contributes  also  to  this  efl^efl:. 
Besides  there  is  no  tendency  to  derangement  from  muscular 
,a6tion. 

This  circumstance  renders  a  diagnosis  of  fra^res  of  the  tibia 
.often  very  difficult,  and  the  difficulty  is  further  increased  by 
the  little  pain  and  inconvenience  produced  by  such  a  fra^ure; 
for  persons  have  been  known  to  walk,  although  the  tibia  wjws 
at  the  same  time  fraftured. 

Whenever  there  is  reason  to  suspect  this  affection,  in  conse- 
quence of  a  blow  or  a  fall  on  the  leg,  the  part  should  be  minute- 
ly examined.  The  fingers  are  to  be  moved  along  the  anterior 
side  of  the  tibia,  the  slightest  inequality  in  which  may  be  ea- 
sily perceived,  on  account  of  its  being  covered  only  by  the 
skin;  and  the  motion  of  the  pieces  may  be  perceived,  by  sei- 
zing the  opposite  ends  of  the  bone  and  pushing  them  in  contra- 
ry directions.  This  motion,  however,  and  the  crepitation 
which  should  accompany  it,  are  very  indistinct,  on  account  of 
the  fibula  not  allowing  the  fractured  portions  to  be  sufficiently 
moved  on  one  another. 

The  patient  conplains  of  a  constant  pain  in  his  leg,  and  par-, 
ricularly  near  the  seat  of  the  fracture.  This  pain  continues  for 
a  much  longer  time  than  that  which  is  the  effect  oif  a  mere 
contusion,  and  it  is  increased  by  walking. 

By  means  of  these  signs,  the  existence  of  this  fracture  may 
be  ascertained;  but  little  is  to  be  done  in  the  treatment  of  it. 
The  slight  derangement  which  has  taken  place,  is  to  be  correct- 
ed by  moving  the  pieces  in  the  direction  opposite  to  that  in 
whicli  the  derangement  has  taken  place;  but  before  giving 


148^  OF    FRACTURES    OF    THE    LEG. 

them  this  motion,  they  should  be  drawn  in  opposite  direflions, 
hi  order  to  diminish  the  friclion  of  the  fraflured  surfaces.  A 
long  compress  is  then  placed  on  the  anterior  part  of  the  leg, 
and  over  that  a  roller  or  circular  bandage;  with  which  the  leg 
being  covered,  three  splints  of  pasteboard,  or  thin  wood,  are 
applied  and  bound  on  by  the  part  of  the  roller  which  remained 
unappUed. 

The  patient  is  to  be  confined  to  his  bed,  and  not  allowed  to 
use  the  affedled  limb  until  the  fracture  is  consolidated.  In 
cases  of  aged  or  adult  persons,  it  would  perhaps  be  more  pru- 
dent to  use  the  ordinary  apparatus  for  fraclures  of  the  leg,  than 
the  roller.  "Whichever  mode  is  adopted,  the  bandage  may  be 
taken  off  on  the  fortieth  or  forty-fifth  day,  at  which  time  the 
consoHdation  is  complete.  The  articulations  of  the  knee  and 
■  foot  are  but  little  affefted  by  this  fradlure,  and  the  slight  stiff- 
ness of  them,  arising  from  inaftivity,  is  soon  removed,  and  the 
patient  is  able  to  walk  about  in  a  few  days. 


SECTION    III. 


Of  Fi'a^ures  of  the  Fibula. 

The  fibula,  though  slenderer  than  the  tibia,  is  less  frequent- 
ly fraftured.  It  is  not  charged  with  the  weight  of  the  body, 
and  its  principal  use  seems  to  be  that  of  preventing  the  disloca- 
tion of  the  foot  outwards,  in  a  forced  abdu6tion.  .  Thus  we  see 
that  it  is  placed  externally,  descends  below  the  articulation  of 
the  tibia  with  the  foot,  and  forms  the  external  ankle.  It  is  be- 
sides more  flexible  than  the  tibia,  and  can  execute  in  its  double 
articulation  with  this  latter  bone  some  obscure  motions,  which 
consume  a  greater  or  less  share  of  any  force  that  might  tend  to 
fra<Slure  it. 

Yet,  from  the  very  nature  of  its  fun(fl:ions,  the  fibula  is  ex- 
posed to  certain  fracflures,  of  which  no  author  has  taken  par- 
ticular notice.  In  every  step  that  is  made  on  an  uneven  ground, 
the  foot  presses  against  the  inferior  extremity  of  this  bone.  By 
this  action  of  the  foot  on  the  external  ankle,  the  fibula  is  pres- 
sed upward,  and  as  the  nature  of  its  articulation  with  the  tibia 
does  not  allow  it  to  ascend  in  any  perceptible  degree,  it  is  for- 
ced to  bend  more  or  less  in  proportion  to  the  force  applied. 


OF    FRACTURES    OF    THE    LEO.  I49 

Tlie  elasticity  of  this  bone  enables  it  for  some  time  to  resume  its 
natural  direction,  when  the  force  is  removed.  But  as  the  same 
force  adls  frequently,  and  is  never  intermitted  but  for  very  short 
intervals,  the  bone  acquires  insensibly  a  permanent  bend,  in- 
stead of  being  perfectly  straight,  as  it  is  in  the  infant.  This  bend 
becomes  more  evident  in  proportion  as  age  advances,  and  as  the 
limb  has  been  used. 

Climbing  anjmals,  such  as  the  squirrel,  and  others,  whose 
feet  are  always  in  a  forced  abduftion,  have  the  fibula  stronger 
in  proportion,  and  more  convex  externally,  than  it  is  in  the 
human  species.  It  has  been  observed  by  Citizen  Cuvier  and 
Dumeril,  that  in  the  animal  called  the  three-toed  sloth,  the 
inferior  extremity  of  the  fibula  is  inserted  into  a  socket  on  the 
superior  surface  of  the  astragalus,  in  such  a  manner  as  that  the 
foot  must  be  considerably  strengthened  by  it,  and  secured 
against  dislocation  by  the  extreme  abdu(5lion  which  this  animal 
is  obliged  to  make,  in  grasping  the  trunks  of  the  trees  oa 
which  he  climbs. 

The  motions  of  adduction  and  abduction,  in  which  the 
sole  of  the  foot  is  turned  inwards  or  outwards,  are  very  limit- 
ed in  the  human  species,  and  much  less  extensive  than  those 
of  flexion  and  extension.  It  sometimes  happens,  however, 
that  the  foot,  from  missing  its  support,  or  being  entangled  by 
something,  is  turned  forcibly  invsrards  or  outwards;  in  which, 
case  the  ligaments  of  the  articulation  are  always  strained,  and 
very  frequently  lacerated.  It  is  in  a  case  of  this  kind,  when 
the  foot  is  forcibly  turned  outwards,  that  the  fibula  is  fractured 
by  the  pressure  of  the  astragalus,  the  dislocation  of  which,  out- 
wards, it  prevents,  when  the  foot  is  forcibly  turned  in  the  same 
direction. 

The  action  of  the  foot  is  always  the  immediate  cause  of 
fracture  produced  in  this  way.  If  the  convexity  of  the  fibula 
outwards  were  uniform,  so  that  the  whole  length  of  the  bone 
should  form  an  arch  of  a  circle;  if  it  were  of  an  equal  thick- 
ness and  strength  in  all  its  parts,  and  if  its  muscular  and  liga- 
mentous connexions  with  the  tibia  were  also  of  an  equal 
strength  in  every  part,  the  fra£lure  would  always  take  place  in 
its  centre:  but  none  of  these  conditions  exist,  and  the  fra<fhire 
takes  place  generally  below  its  middle  half.  If  the  abduftion 
of  the  foot  has  been  very  violent  and  sudden,  the  fibula  may 
be  fradtured  at  about  an  inch  above  its  lower  extremity,  by 
which  the  external  ankle  is  separated  from  the  body  of  the 
bone. 


150  or    FRACTURES    OF    THE    LEO, 

To  the  fraftures  produced  by  this  cause  are  to  be  added 
those  resulting  from  a  fall,  or  a  blow  on  the  external  side  of 
the  leg,  in  which  the  bone  always  yields  in  the  part  to  which 
the  force  is  immediately  applied,  and  in  a  diredlion  opposite  to 
its  natural  curve. 

Whatever  be  the  manner  in  which  a  frafture  of  the  fibula 
is  produced,  the  pieces  are  not  susceptible  of  the  longitudinal 
derangement;  but  are  in  all  cases  drawn  a  little  towards  the  ti- 
bia, by  the  muscles  placed  in  the  interval  between  themv 
Hence  a  fradlure  of  this  bone  will  be  best  ascertained  by  press- 
ing the  fra£lured  portions  inward,  as  it  is  in  that  diredlion  that 
their  motion  can  be  best  perceived.  This  symptom,  and  cre- 
pitation, which  is  a  consequence  of  it,  may  be  also  observed 
in  the  abdudlion  and  addudiion  of  the  foot.  These  signs  are 
more  evident  when  the  fradture  takes  place  near  the  inferior 
extremity,  than  when  it  happens  near  the  superior,  which  is 
covered  with  thick  muscles.  But  a  fraclure  of  the  lower  part 
may  be  very  difficult  to  be  ascertained,  when  the  articulation 
of  the  foot  has  been  at  the  same  time  violently  strained,  and 
the  inflammation  and  swelling  have  arrived  at  a  great  height. 
In  cases  of  this  nature,  some  pr addition ers  turn  all  their  atten- 
tion to  the  afFe£lion  of  the  articulation,  that  is  to  reduce  the 
luxation  of  the  astragalus,  and  combat  the  inflammatory  sympr 
toms,  without  doing  any  thing  for  the  fradlure. 

But  so  imperfedt  a  mode  of  treatment  must  be  attended  with 
the  worst  consequences.  The  peronei  muscles,  which  extend 
the  foot  by  raising  its  external  edge,  and  turning  its  sole  out- 
ward, aft  incessantly,  and  draw  the  foot  gradually  into  that 
position.  The  fraftured  portions  are  deranged  longitudinally, 
the  inferior  being  drawn  upward  along  the  internal  side  of  th^ 
superior.  The  astragalus  is  carried  under  the  internal  ankle, 
and  forms  a  considerable  tense  tumour  there;  the  skin  becomes 
inflamed  and  ulcerated  at  this  part,  and  a  fistula  is  formed, 
which  communicates  with  the  articulation  of  the  foot.  The 
patient  cannot  support  himself  on  the  afFefted  limb,  and  ir^ 
time  the  symptoms  become  more  and  more  alarming,  and  may 
lead  to  the  necessity  of  amputating  the  part.  Fabre  quotes  twQ 
examples  of  the  Vad  consequences  resulting  from  negledling 
a  fracture  of  the  fibula;  they  are  to  be  found  in  his  Researches 
on  certain  Points  of  Physiology  and  Pathology.  I  have  my- 
self seen  the  foot  distorted,  and  the  fracture  not  consolidated, 
in  the  case  of  an  old  man  who  died  of  a  malignant  fever,  in 
one  of  the  medical  wards  of  La  Charite. 


OF    FRACTURES    OF   THE    LEG.  I5I 

It  will  therefore  be  prudent,  in  every  case  of  a  strained  foot, 
to  examine  carefully  the  lower  extremity  of  the  fibula,  and  to 
apply  an  appropriate  apparatus,  if  there  be  the  slightest  sus- 
picion of  a  frafture.  The  first  step  of  the  treatment  should  be 
to  cover  the  affedled  part  with  emollient  poultices,  and  to  take 
some  blood  from  the  arm ;  and  if  it  be  found  that  the  bone  is 
fractured,  so  soon  as  the  swelling  and  inflammation  are  abated, 
Scultet's  bandage  should  be  applied,  and  the  distortion  of  the 
foot  prevented  by  means  of  two  splints,  which  descend  fi"onx 
above  the  knee,  to  a  short  distance  beyond  the  foot  externally, 
and  internally  as  low  as  the  ankle.  It  is  perhaps  superfluous  to 
repeat  that  the  splints  should  be  rolled  in  a  splint-cloth,  and 
tied  on  with  bands,  and  that  bags  of  chaff  should  be  placed 
between  them  and  the  leg,  in  the  depressed  parts. 

This  apparatus  should  be  continued  for  a  month,  and  fre- 
quently removed,  in  order  to  renew  the  emollient  applications. 
In  this  lapse  of  time,  the  frafture  generally  consolidates,  but  a 
stiffness  remains  in  the  joint,  of  which  it  will  be  prudent  to 
Warn  the  patient.  This,  however,  will  be  removed  in  a  few 
months  by  bathing  and  fridtion,  but  above  all  by  exercise,  the 
suspension  of  which  was  its  principal  cause. 

If  the  fradhire  take  place  towards  the  middle  part  of  the 
bone,  the  ordinary  apparatus  for  frafture  of  the  leg  should 
be  applied,  and  thick  compresses  placed  on  the  anterior  and 
posterior  sides  of  the  leg,  by  means  of  which  the  antero-pos- 
terior  diameter  being  increased,  the  bandage  can  adt  in  that  di- 
redlion,  and  press  the  fleshy  parts  into  the  interosseous  inter- 
val, and  thus  prevent  the  fradiured  portions  from  obeying  their 
tendency  to  approach  the  tibia.  But  preserving  the  interos- 
seous interval  is  not  so  important  here  as  in  the  fore-arm,  be- 
cause in  the  former  it  merely  serves  to  lodge  some  muscles^ 
the  foot  not  having  to  execute  any  motions  which  require  the 
rotation  of  the  fibula  on  the  tibia. 


1^1 


CHAPTER  XVII. 


OF  FRACTURES  OF  THE  BONES  OF  THE  FOOT. 


SECTION   I. 


Of  the  FraBures  of  the  Os  Calcis. 


THE  solidity  of  this  bone,  the  three  dimensions  of  which 
are  nearly  equal,  renders  it  but  little  liable  to  be  fracElu- 
red.  The  causes  by  which  it  may  be  fraftured  are  muscular  ac- 
tion and  external  violence,  and' in  this  respeft  it  resembles  the 
olecranon  and  patella.  The  violent  and  instantaneous  contrac- 
tion of  the  gastrocnemii  muscles  is  sufficient  to  detach  from  the 
remainder  of  the  bone  that  part  of  it  called  the  tuberosity,  into 
which  the  tendo  Achillis  is  inserted,  and  which  extends  back- 
ward beyond  the  astragalus.  Though  the  gastrocnemii  muscles 
are  at  least  as  strong  as  the  extensors  of  the  arm  or  leg,  yet 
fra£lures  of  the  os  calcis  are,  on  account  of  its  thickness,  much 
less  frequent  than  those  of  the  patella  or  olecranon.  Fradlures 
of  it  are  also  less  frequent  than  the  rupture  of  the  tendo  Achil- 
lis, the  contrary  to  which  takes  place  with  respe<Sl  to  the  ten- 
dons of  the  extensors  of  the  arm  and  leg,  which  are  stronger 
than  the  osseous  parts  to  which  they  are  attached. 

Some  rare  examples  of  fracSlure  of  the  os  calcis  from  muscu- 
lar a6lion  maybe  cited:  that,  for  instance,  of  a  woman  detain- 
ed against  her  will  at  La  Salpetriere.  She  converted  her  sheets 
into  a  rope,  and  by  means  of  them  descended  from  her  win- 
dow; but  the  sheets  not  reaching  to  the  ground,  she  let  her- 
self drop  on  her  feet.  On  touching  the  ground,  she  heard  a 
crack  in  one  of  her  heels,  and  fell  without  the  power  of  rai- 


OF    FRACTURES   OF    THE    OS  CALCIS.  I  Jj 

sing  herself.     On  examination  the  os  calcis  was  found  to  be 
fraihired. 

The  existence  of  this  fracture  is  discovered  by  the  circum- 
stances of  the  case:  a  fall  on  the  sole  of  the  foof,  a  crack 
heard  in  the  moment  of  the  fall;  pain,  which  is  increased  by 
the  motion  of  the  part;  the  almost  absolute  impossibility  of 
standing  or  walking;  a  greater  or  less  sweUing  of  the  heel; 
the  mobility  and  elevation  of  that  part  of  the  os  calcis  into 
which  the  tendo  AtJhillis  is  inserted;  finally,  the  crepitation 
and  interval  between  the  fractured  portions — are  all  marks 
which  separately  or  conjointly  lead  to  the  discovery  of  the 
fradture,  it  may  be  observed,  however,  that  the  separation  of 
the  fra6lured  portions  is  not  easily  ascertained,  on  account  of 
the  thickness  of  the  integuments. 

In  setting  this  frafture,  it  is  necessary  to  extend  the  foot  on 
the  leg,  and  to  bend  the  leg  on  the  thigh.  In  this  position  the 
two  portions  of  the  os  calcis  can  be  very  easily  brought  into 
contain:,  the  superior  of  which  is  drawn  upward  by  the  gastroc- 
nemii  muscles. 

The  foot  and  leg  are  kept  in  this  position  all  the  time  neces- 
sary for  the  consolidation,  by  means  of  the  slipper  invented  by 
J.  L.  Petit  for  a  rupture  of  the  tendo  Achillis. 

The  uniting  bandage  used  for  transverse  wounds  may  be 
substituted  for  the  slipper,  when  from  local  circumstances,  the 
latter  cannot  be  had;  but  it  must  be  modified  as  follows:  the 
end  of  a  bandage  is  placed  on  the  superior  surface  of  the  foot, 
whence  the  bandage  is  reverted  on  the  sole,  and  the  end  is 
made  fast  by  circular  casts  round  the  foot:  this  bandage  is  then 
drawn  along  the  posterior  side  of  the  leg  to  the  ham  (the  foot 
being  previously  extended),  on  which  part  it  is  fixed  by  other 
circular  casts:  it  is  thence  brought  downward  forcibly,  and  the 
application  of  it  terminated  by  rolling  along  the  leg  what  re- 
mains. To  this  bandage  might  be  added  a  long  compress,  the 
middle  part  of  which  should  be  applied  above  the  posterior 
portion  of  the  os  calcis,  and  the  exti*  mities  crossed  on  the  su- 
perior surface  of  the  foot,  and  turned  under  the  sole.  This 
compress  may  be  fixed  by  a  bandage  rolled  on  the  foot  in  the 
shape  of  the  figure  8. 

The  union  of  this  frafture  is  effedted  in  thirty  or  forty  days, 
at  the  end  of  which  time  the  patient  may  be  allowed  to  bend 
his  foot.  He  must,  however  for  some  days,  avoid  any  forced 
flexion  of  the  foot,  as  also  an  excessive  extension  by  rising  nn 
his  toes. 

20 


1^4  OF    WOUNDS,    ANft 

The  other  bones  of  the  tarsus,  as  the  astragalus,  cuboide?, 
scaphoides,  and  the  three  ossa  cuneiformia,  are  susceptible  on- 
ly of  comminutive  fradlure.  The  same  may  be  said  of  the 
bones  of  the  metatarsus,  and  the  phalanges  of  the  toes.  On 
the  treatment  of  fradhires  of  these  bones  we  have  nothing  to 
add  to  what  has  been  already  said  in  general  on  compound 
fractures,  op  in  particular  on  fradures  of  the  bones  of  the  hand*. 


CHAPTER  XVIlt. 


OF  WOUNDS,   AND  DENUDATION  OF  BONES. 

THE  bones  may  be  stripped,  not  only  of  the  integuments/ 
muscles,  &c.  by  which  they  are  naturally  covered,  but- 
also  of  the  periosteum,  which-  is  their  intimate  and  appropri- 
ate covering. 

Cutting  or  eontundlng  instruments  may  produce  this  denu- 
dation of  the  bone  without  injuring  its  substance,  or  they  may 
cut  or  contuse  its  external  fibres.  Th^se  two  cases  must  be 
carefully  distinguished,  as  the  contusion  of  th€  bone  is  attend- 
ed with  consequences  much  more  serious  thaft  those  of  a  simple 
denudation; 

If  the  bone  has  been  merely  stripped  of  its  periosteum  ancb 
integuments,  and  these  parts  are  immediately  replaced,  so  a» 
to  exclude  the  contact  of  the  air  and  bandages,  the  reunion  of 
the  periosteum  is  found  to  take  place  in  a  very  short  time. 
But  if  the  external  lamin>,  of  the  bone  have  been  contused,  or 
if  its  surface  has  been  left  a  long  time  exposed  to  the  adtion  of 
the  air,  or  to  the  fridlion  of  bandages,-  exfoliation  becomes  a- 
necessary  consequence.  All  the  external  laminae  must  separate*, 
and  before  this  separation  is  effected,  the  cicatrization. of  the 
external  wound  would  be  rather  injurious.  Should  the  wound  in' 
the  integuments  be  prematurely  closed,  purulent  matter  will 
continue  to  form  underneath,  the  contused  laminse  will  exfo- 
liate, an  abscess  will  point  externally  and  burst  spontaneously,. 


DENU,pATION    Of    BONES.  i^^ 

and  tfee  matter  that  escapes  from  them  wiU  contain  small  splint- 
ers of  bone.  Old  age  is  unfavourable  to  the  healing  of 
wounds  and  contusion  of  the  bones;  because,  as  ihe  cure  can 
be  effected  only  by  means  of  the  vascular  texture  of  the  bone 
and  periosteum,  the  turgescence  and  expansion  of  this  must 
be  slow  and  difficult  in  proportion  to  the  person's  age.  The 
treatment  adapted  to  the  different  cases  is  as  follows: 

If  the  bone  be  simply  laid  bare,  the  integuments,  if  not 
completely  separated,  should  be  instantly  replaced.  This  pre- 
cept holds  good  in  all  cases,  whatever  may  be  the  patient's  age, 
if  the  bone  has  not  been  already  a  long  time  exposed  to  the 
contact  of  the  air.  At  the  same  time  it  must  be  allowed  that 
it  is  very  difficult  to  know  by  mere  inspe<Stion  whether  the 
bone  be  contused  or  not;  but  should  that  be  the  case,  and  even 
should  suppuration  and  exfoliation  be  inevitable,  no  bad  con - 
Gequence  can  result  from  the  attempt  to  produce  an  immediate 
cicatrization;  whereas,  in  the  contrary  event,  the  duration  of 
the  treatment  will  be  much  abridged.  If  it  be  impossible  to 
unite  the  wound  by  the  first  intention,  its  lips  are  to  be  kept 
separate  by  lint  interposed,  and  the  whole  is  to  be  lightly  co- 
vered. In  a  short  time  granulations  appear,  and  the  external 
laminse  of  the  bone  exfoliate.  Sometimes,  however,  and  par- 
ticularly in  young  persons,  the  bone  becomes  soft  and  red,  and 
granulations  arise  from  it,  which  bleed  from  the  slightest  x;ause. 
It  has  been  said,  that  the  bone  exfoliates  insensibly  in  this 
case;  but  this  observation  is  not  found  tp  be  true:  the  laminse 
of  the  bone  are  not  broken  down,  dissolved,  and  carried  off 
by  suppuration.  The  change  consists  of  a  softening  of  the 
bone,  and  conversion  of  it  into  a  fleshy  substance,  which  unites 
with  the  soft  parts. 

In  this  last  mentioned  case  the  cure  is  much  mor-e  prompt 
than  when  a  real  exfoliation  takes  place.  The  process  of  ex- 
foliation resembles  that  of  the  separation  of  gangrenous  es- 
chars: the  mode  in  which  the  separation  is  fffefted  is  equally 
unknown  in  both  cases.  In  exfoliation,  it  is  merely  known 
that  the  subjacent  vessels  grow  turgid,  expand,  and  pullulate, 
and  that  a  line  of  separation  is  observed  between  the  contused 
"iaminoe  and  the  sound  part  of  the  bone.  The  former  are  u-n- 
dermined,  as  it  were,  and  their  connexion  shaken  by  the  pu- 
rulent matter  formed  under  them,  and  at  length  are  entirely 
detached,  and  may  be  easily  removed  by  the  fingers  or  a  for- 
*;eps.     When  the  bottom  of  the  wound  is  entirely  freed,  the 


156  OF    WOUNDS,     &C.     OF    BONES. 

granulations  that  arise  from  it  unite  with  the  soft  parts,  and  in 
a  short  time  the  wound  is  cicatrized. 

Various  processes  have  been  employed  for  expediting  the 
exfoliation.  Thus  the  ancients  covered  the  bone  with  pledgits 
of  lint  impregnated  with  spirits,  or  with  a  tin(n:ure  of  myrrh 
and  aloes;  but  it  is  found  that  these  applications  retard  the  ex- 
foliation by  opposing  the  expansion  of  the  vessels ;  for  which 
reason  they  have  been  laid  aside,  and  oily  relaxing  applications 
have  been  substituted  for  them. 

•  It  has  been  proposed  to  perforate  in  different  parts  the  lami- 
nse  which  are  to  exfoliate,  on  the  supposition  that  this  pradlice 
facilitates  the  growth  of  the  granulations.  The  perforations 
have  certainly  this  effedl,  but  the  granulations,  by  shooting  up 
throuch  them,  retain  the  lamina:  rather  than  aid  their  exfolia- 
tion:  each  vessel  spreadmg  as  it  rises,  and  assummg  in  some 
respeft  the  shape  of  a  broad-headed  nail.  It  will  then  be  more 
prudent  to  limit  the  treatment  to  the  use  of  unctuous  or  emol- 
lient applications.  By  means  of  these  remedies,  the  texture  of 
the  part  will  be  sufficiently  relaxed,  and  the  developement  of 
the  vessels  facilitated.  But  if  the  portion  of  bone  to  be  exfo- 
liated be  very  considerable  and  deep  seated,  these  applications 
are  nearly  useless,  at  least  their  effect  must  be  very  trifling; 
then  we  must  content  ourselves  with  covering  the  part  with 
lint,  and  trusting  to  time  and  nature  for  effedling  the  separa- 
tion. 

Though  the  exfoliation  be  complete,  as  may  be  known  by 
the  motion  of  the  piece,  it  may  still  happen  that  the  circumfe- 
rence of  the  detached  portion  may  be  encroached  on  by  the 
growth  of  the  soft  parts,  and  thus  prevented  from  separating. 
In  this  case  it  will  be  necessary  to  disengage  it  by  making  an 
incision  in  some  point  of  the  circumference  of  the  wound,  af- 
ter which  it  may  be  drawn  out  by  the  fingers  or  a  forceps.  In 
general,  there  is  but  very  little  difficulty  in  removing  it. 

The  action  of  cutting  instruments  is  not  always  limited  to  the 
mere  denudation  of  the  bone;  they  sometimes  completely  divide 
it:  this,  however,  is  but  a  rare  occurrence.  It  sometimes  hap- 
pens that  a  part  of  the  bone  is  cut  off",  of  which  there  are  nu- 
merous instances  in  wounds  of  the  head,  where  a  part  of  the 
pariotal  bone,  with  its  pericranium,  a  portion  of  the  occipito- 
frontalis  muscle  and  hairy  scalp,  have  been  entirely  separated 
by  a  blow  of  a  sword. 

When  a  wound  of  the  soft  parts  is  accompanied  by  a  similar 
affedlion  of  the  subjacent  bone,  an  immediate  reunion  of  the 


OF    NECROSIS.  157 

soft  parts  must  not  be  attempted.  Lint  is  to  be  gently  intro- 
duced into  the  fissure,  and  the  wound  healed  from  the  bottom; 
for  a  solid  cicatrix  of  the  soft  parts  cannot  be  expected  until 
the  wound  in  the  bone  is  first  cicatrized. 

If  the  bone  of  one  of  our  limbs  be  cut  quite  through,  as  in  the 
cases  mentioned  by  La  Peyronie,  Warner,  and  others  j  and  if  a 
piece  of  flesh  remain  undivided,  which  contains  the  principal 
vessels  of  the  limb,  it  will  be  prudent  to  reunite  the  parts,  and 
place  the  limb  in  the  apparatus  used  in  cases  of  frafture  of  the 
part. 

The  time  necessary  for  the  remiion  of  the  parts  in  cases  of 
this  nature  is  full  as  long  as  that  in  those  of  frafture,  and  the 
consolidation  is  effedled  in  the  same  manner  as  in  the  former 
case. 


CHAPTER  XIX. 


OF  NECROSIS. 


THAT  affection  of  bones  by  which  a  part  of  their  sub- 
stance is  deprived  of  the  vital  principle,  has  been  termed 
necrosis:  the  affected  part  of  the  bone,  in  this  case,  bears  a 
stricl  analogy  to  that  of  soft  parts  in  which  a  gangrene  has  taken 
place.  This  disease  was  not  distinguished  from  caries  by  the 
ancients,  and  it  has  been  termed  "  dry  caries"  by  some  of  the 
moderns.  Necrosis  and  caries  are,  however,  essentially  dif- 
ferent. 

Osseous  parts  attacked  by  necrosis  are  absolutely  deprived  of 
the  vital  principle:  but  this  is  not  the  case  when  they  are  simply 
carious;  for  caries  is  an  affeiTlion  exactly  analogous  to  foul  and 
corroding  ulcers  of  the  soft  parts. 

All  the  bones  of  the  body  are  subject  to  necrosis,  but  some 
are  more  frequently  attacked  by  it  than  others  j  the  broad 


158  or    NECROSIS. 

boiies,  for  instance,  and  those  which  are  but  lightly  covered 
with  soft  parts,  such  as  the  bones  oi  the  skull,  the  lower  jaw, 
the  clavicle,  the  scapulae,  the  humerus,  femur,  and  tibia.  The 
short  bones  are  seldom  attacked  by  it,  but  are  much  more  sub- 
jeft  to  caries.  The  afFe£lion  may  be  either  partial,  or  it  may 
extend  to  the  entire  bone.  Thus  we  find  a  long  bone  afFedled 
in  some  part  of  its  length,  or  entirely  diseased  from  one  end 
to  the  other,  and  broad  hones  affefted  only  in  their  external 
iaminx,  or  in  their  entire  substance. 

The  middle  portion  of  long  bones,  or  that  part  of  them 
which  is  most  compaft,  least  porous,  and  consequently  least 
endued  with  the  vital  principle,  is  that  which  necrosis  most  ge- 
nerally attacks :  the  extremities  of  these  bones,  and  in  general 
all  spongy  bones,  are  much  less  liable  to  it.  This  disease  never 
extends  to  the  articulations,  even  when  the  whole  diameter  of 
the  middle  part  of  the  bone  is  affected  by  it:  the  extremities 
covered  with  cartilage  separate  from  the  dead  part  of  the  bone, 
and  if  this  be  removed  by  nature  or  art,  they  unite  with  the 
ossified  periosteum,  which  occupies  the  place  of  the  separated 
portion. 

When  the  necrosis  is  superficial,  the  superior  lamellse  are 
separated  from  the  rest  of  the  bone;  but  this  separation  is  al- 
ways preceded  by  a  suppuration  produced  by  the  irritation  given 
to  the  surrounding  soft  parts  by  the  dead  portion  of  bone.  It 
is  to  be  observed,  that  no  part  of  the  substance  of  the  dead 
portion  of  bone  goes  to  the  formation  of  this  purulent  matter; 
for  it  seems  to  be  not  only  incapable  of  furnishing  matter  for 
the  formation  of  pus,  but  is  entirely  without  the  sphere  of  vi- 
tal action. 

if  a  broad  bone,  as  the  os  frontis,  for  instance,  be  attackpd, 
the  skin  over  the  aftedled  part  tumefies,  becomes  inflamed,  and 
assumes  a  brown  or  violet  colour-,  it  grows  gradually  thinner, 
bursts  at  length,  and  gives  issue  to  the  purulent  matter  contain- 
ed under  it.  The  necrosis  of  the  bone  is  then  ascertained  by 
introducing  a  probe,  which  is  found  to  pass  on  a  rough  and 
naked  surface,  if  the  afieclion  of  the  bone  really  exist. 

In  a  case  of  complete  necrosis  of  a  long  bone,  the  limb  swells 
at  the  part  affefled,  and  a  hard  and  painful  tumour  is  formed 
on  it.  Abscesses  form  at  various  points,  they  burst,  and  thei> 
openings  degenerate  into  fistula*.  The  discharge  from  these  in 
the  commencement  is  white  and  inodorous,  but  becomes  se- 
rous and  fetid  in  a  short  time.  This  matter  is  sometimes  ab- 
£orbed  in  such  quantity  as  to  produce  marasmus,  hedlic  fevet. 


or  NECROSIS.  159 

&c.  In  cases  of  necrosis,  in  which  the  whole  bone  Is  afFeftcd, 
the  periosteum  separates  from  the  portion  of  diseased  bone, 
its  vessels  seem  to  take  on  a  new  aftion,  a  calcareous  phosphr.te 
is  deposited  in  its  texture,  it  acquires  hardness,  and  in  time 
forms  a  cylinder,  in  which  the  dead  part  of  the  bone  is  in- 
cluded. This  new  bone,  which  is  in  fa£l  the  periosteum  os- 
sified, is  rough  on  its  surface,  and  has  but  a  distant  resemblance 
to  that  which  it  replaces.  Various  holes  are  observed  in  it, 
through  which  the  purulent  matter  and  mouldering  portions  of 
bone  escape,  the  fistulous  openings  in  the  soft  parts  being  con- 
tinuations of  these  holes,  and  the  muscles  of  tlie  limbs  are  in- 
serted into  it. 

The  dead  part,  completely  separated  from  the  sound,  and 
enclosed  by  the  indurated  periosteum,  is  called  sequestra:  this 
separation  is  perfedlly  analogous  to  that  of  nrjortified  soft  parts. 

The  promptitude  with  which  gangrened  soft  parts  are  sepa- 
rated, is  much  greater  than  that  with  which  a  dead  portion  of 
bone  is  detached ;  but  this  difference  is  to  be  entirely  attributed 
to  the  state  of  the  vital  energy  of  the  parts,  which  is  much  more 
considerable  in  one  case  than  in  the  other. 

The  causes  of  necrosis  may  be  divided  into  internal  and  ex- 
ternal; the  latter  are  blows,  excessive  pressure,  imprudent  ap- 
plications of  caustics ;  as  happened  in  the  case  of  a  woman  who 
had  caustic  potash  applied  to  an  exostosis  on  the  internal  side 
of  the  tibia.  But  necrosis  is  most  frequently  produced  by  an 
internal  cause,  such  as  scrofula,  or  syphilis.  In  persons  thus 
constitutionally  affe£led,  a  blow  or  other  external  accident,  may 
prove  an  exciting  cause  of  the  disease. 

By  whatever  cause  produced,  the  following  symptoms  cha- 
rafterize  it:  excruciating  pains  in  the  part  affecSbed,  which  no 
emollient  nor  sedative  application  can  assuage.  As  there  is  no 
visible  swelling  in  the  commencement  of  the  disease,  these 
pains  are  frequently  attributed  to  rheumatism.  The  pain 
which  was  felt  at  first  but  about  the  middle  of  the  bone,  extends 
towards  its  extremities,  if  the  bone  affe<Sted  be  a  long  one  :  tha 
part  swells,  the  skin  becomes  inflamed,  and  the  tumour,  which 
was  hard  at  first,  grows  soft  in  different  parts,  or  abscesses 
form  in  it,  which  burst,  and  whose  openings  degenerate  into 
fistulas.  The  surface  of  the  bone,  if  not  deep  seated,  as  the 
tibia  for  instance,  may  be  seen  through  this  opening;  in  which 
case  the  nature  of  the  disease  may  be  ascertained  beyond  all 
doubt ;  but  an  equal  certainty  may  be  had.  when  the  bene  U 


i6o  OF    NECROSrS. 

covered  by  a  great  depth  of  soft  parts,  by  the  insertion  of  a 
probe. 

There  is  at  first  a  copious  discharge  of  purulent  matter,  but 
the  quantity  gradually  diminishes,  and  splinters  of  dry  bone, 
coloured,  as  if  they  had  been  buried  a  long  time  in  the  earth, 
come  out  with  the  pus.  The  disease  may  be  said  to  be  at  its 
height  at  this  period,  for  now  the  dead  part  is  separated  by  the 
vital  energy  of  the  sound.  By  introducing  a  probe  at  this  time, 
pieces  of  the  bone  are  felt  detached  and  loose.  These  symp- 
toms of  necrosis,  evident  enough  in  affeftions  of  the  long  bones 
covered  with  thick  muscles,  are  still  more  so  in  cases  of  flat  su- 
perficial bones,  as  those  of  the  skull  for  instance:  in  affections 
of  the  latter,  the  skin  becomes  first  thick,  hard,  and  reddish; 
but  it  soon  bursts,  and  an  ulcer  is  formed  in  it. 

The  prognosis  varies  in  this  disease  according  to  the  bone  af- 
fedted,  and  the  circumstances  with  which  it  may  be  oompli- 
cated. 

If  the  disease  be  confined  to  the  surface  of  a  flat  bone,  or 
though  it  should  aftcCl  it  quite  through,  it  is  not  very  dange- 
rous, and  nature  alone  effects  the  cure.  If  the  assistance  of  art 
be  necessary,  it  is  only  in  combating  the  disease  of  the  system. 
However,  if  there  be  a  large  surface  affected,  and  if  the  intro- 
duction of  instruments  for  the  purpose  of  extracting  the  splint- 
ers be  difficult,  the  prognosis  becomes  more  unfavourable.  Ne- 
crosis, when  confined  to  the  surface  of  the  middle  part  of  long 
bones,  is  equally  free  from  danger  as  in  the  former  case,  and 
nature  alone  effeCts  a  cure.  But  the  prognosis  is  far  different 
when  a  large  portion  of  the  bone  is  affeCted,  and  when  this 
portion  is  contained  in  the  cavity  of  the  cylinder  formed  by 
the  ossified  periosteum;  for  though  nature  has  been  able  to  se- 
parate it,  yet  the  assistance  of  art  is  necessary  to  remove  it 
from  its  osseous  covering. 

In  cases  of  necrosis,  in  which  the  dead  bone  is  entirely  in- 
cluded in  that  newly  formed,  the  prognosis  may  vary  according 
to  the  state  of  the  soft  parts  of  the  limb,  the  age  and  strength  of 
the  patient,  and  the  form  of  the  new  osseous  substance.  The 
tumefaction  of  the  limb  may  be  excessive,  the  fistulx  numerous, 
the  suppuration  abundant,  and  the  strength  may  be  reduced  by 
colliquative  diarrhoea  and  heCtic  fever.  In  such  circumstances 
the  danger  is  much  greater  than  if  the  suppuration  were  trifling, 
the  patient  young  ami  healthy:  and  the  danger  will  be  still  less 
if  the  new  bone  be  naturally  perforated,  so  as  that  the  old  one 
may  be  drawn  out. 


OF    NECROSIS.  l6l 

The  surgeon,  whose  art  is  so  useful  in  most  diseases  of  the 
bones,  can,  in  cases  of  necrosis,  be  but  a  simple  speiflator  of 
the  operations  of  nature,  which  are  frequently  successful:  it 
may  be  said  with  truth,  that  necrosis  proves  the  efficacy  of  na- 
ture, and  the  insufficiency  of  art.  Art  can  assist  nature  only 
in  removing  that  part  of  the  bone  which  the  vital  principle  has 
abandoned ;  as  has  been  amply  shewn  in  the  Memoirs  of  the 
Academy  of  Surgery,  in  David's  Treatise  on  Necrosis,  and 
more  particularly  in  a  Latin  work  on  that  disease,  by  M.  Weid- 
man.  If  the  necrosis  be  superficial,  or  not  very  extensive,  na- 
ture alone  is  sufficient  to  remove  effedlually  the  diseased  part; 
but  art  assists  in  cases  of  deep-seated  necrosis,  in  which  the 
dead  bone,  after  its  complete  separation,  is  enclosed  in  the 
new. 

The  treatment  adapted  to  the  necrosis  of  broad  or  flat  bones, 
or  that  of  long  bones  when  the  disease  is  confined  to  the  sur- 
face of  their  middle  part,  is  very  different  from  that  which 
should  be  followed  when  the  necrosis  has  seized  the  entire  body 
of  the  latter.  We  shall  therefore  explain  these  different  modes 
of  treatment  successively. 

When  one  of  the  large  bones  of  the  skull  is  attacked  by  necro- 
sis in  any  part  of  its  surface,  nothing  is  to  be  done  until  exfolia- 
tion takes  place.  The  progress  of  this  process  is  marked  by  an 
inflammatory  circle  round  the  part  to  be  separated,  by  a  fissure 
which  succeeds,  and  marks  the  same  circumference,  and  which 
grows  wider  and  wider  every  day.  If  at  this  time  the  diseased 
portion  be  struck  with  a  probe,  a  noise  is  heard  which  indi- 
cates an  empty  space  under  it :  it  becomes  loose  soon  after,  and 
may  be  very  easily  removed.  The  separation  of  it  may  be  ac- 
celerated by  stirring  it  every  day,  but  it  is  useless  to  apply  any 
instrument  for  the  purpose  of  thinning  it;  for  the  exfoliating 
of  a  thick  lamella  is  just  as  easy  as  that  of  a  thin.  The  use  of 
the  trepan  is  equally  inapplicable  for  this  purpose,  as  it  is  im- 
possible to  know  beforehand  to  what  depth  the  exfoliation  will 
take  place,  and  if  that  depth  be  not  entirely  taken  off,  the 
slightest  lamella  which  remains  will  be  just  as  troublesome  as  if 
the  whole  remained:  nature  will  require  as  much  time  to  se- 
parate it,  as  if  it  had  been  much  thicker.  We  have  already 
pointed  out  the  inutility  of  perforating  the  affedled  part  of  the 
bone,  with  the  intention  of  facilitating  the  exfoliatioiV  We 
have  also  remarked,  that  un£tuous  and  emollient  bodies  are 
better  topical  applications  than  spirituous  irritating  substances, 
such  as  tinflures  of  aloes  and  myrrh;  or  than  caustic,  which. 


•l62  OF    NECR0SJ3. 

br  irritating  the  subjacent  parts,  often  causes  the  disease  tO'ex'- 
tend. 

It  is  plain  that  the  topical  afFeftion  will  continue  to  extend 
incessantly,  when  it  depends  on  a  constitutional  disease;  there- 
fore, while  nature  tends  to  remove  the  former,  it  will  be  neces- 
sary to  oppose  appropriate  remedies  to  the  general  disease, 
whether  venereal,  cancerous,  scrofulous,  or  scorbutic. 

If  one  of  the  bones  of  the  cranium  be  affected  with  necro- 
sis, and  the  brain  be  compressed  by  pus,  it  will  be  necessary  to 
use  the  trepan,  as  advised  by  Quesnai,  in  order  to  remove  the 
pus  accumulated  on  the  dura  mater.  The  trepan  is  not  applied 
in  this  case  against  the  disease  itself,  but  against  a  very  dange- 
rous consequence  of  it.  In  stirring  the  piece,  in  order  to  ac- 
celerate its  separation,  care  must  be  taken  not  to  break  it,  as 
the  extraction  of  the  remaining  portion,  generally  covered  with 
soft  parts,  might  be  difficult.  It  is  found  necessary  in.  many 
cases  to  make  use  of  a  spatula,  or  some  such  instrument,  to 
disengage  the  splinter  from  the  granulations  which  encroach  on 
its  surface,  and  take  root  as  it  were  in  its  inequalities:  this  may 
take  place  to  such  a  degree,  that  it  may  be  sometimes  necessa- 
ry to  make  an  incision  into  the  soft  parts,  in  order  to  extract 
more  readily  th€  portion  of  dead  bone. 

When  the  piece  is  extracted,  the  disease  is  reduced  to  the 
state  of  a  simple  wound.  The  granulations  which  arise  from 
the  diploe,  or  dura  mater,  wh«n  any  of  the  bones  of  the  skull 
has  exfoliated,  become  the  foundation  of  a  solid  cicatrix.  The 
bone  always  remains  thin  in  that  part;  and  it  has  been  found 
necessary  to  proteft  the  part  of  the  cranium,  from  which  an  ex- 
foliation of  this  kind  took  place,  with  a  piece  of  leather  or 
pasteboard. 

When  the  exterior  lamellae  of  a  long  bone  are  afFefted  with 
necrosis,  the  treatment  is  precisely  the  same.  If  it  be  ascer- 
tained by  the  introduction  of  a  probe  through  a  fistulous  open- 
ing, that  an  exfoliation  of  the  bone  has  taken  place,  an  incision 
must  be  made  for  the  purpose  of  extracting  the  exfoliated  piece. 
But  when  this  disease  affeCts  the  whole  of  a  cylindrical  bone, 
and  when  the  periosteum  is  ossified  around  the  diseased  bone, 
it  will  be  necessary  to  acquire  the  greatest  certainty  of  the  com- 
plete separation  of  the  decayed  portion  from  the  new  one.  "In 
order  to  ascertain  this,  we  attend  to  the  duration  of  the  disease, 
but  principally  to  the  motion  that  maybe  communicated  to  the 
decayed  portion,  by  introducing  a  probe  through  one  of  the 
fistulous  openings.     It  happens  sometimes  that,  in  moving  the 


OF  NECRosrs.  i6;^ 

limb,  aJioise  may  be  heard  from  the  colliiion  of  the  decayed 
bone  against  the  parietes  of  the  new  one. 

When  nature  has  done  her  duty,  the  assistance  of  art  must 
be  called  in  to  complete  the  cure;  but  the  extraclion  of  the 
dead  bone  is  an  operation  of  a  painful  and  hazardous  nature, 
and  should  not  be  undertaken  without  refle6ting  very  seriously 
on  its  probable  consequences,  and  on  those  of  the  disease  if  left 
to  itself.  The  operation  is  extremely  difficult  when  the  diseased 
bone  is  covered  with  a  great  number  of  very  thick  muscles,  as 
the  femur  for  instance.  In  that  case  saving  the  patient's  life 
alone,  endangered  by  the  excessive  suppuration  and  absorption 
of  the  pus,  is  the  only  thing  that  can  induce  the  surgeon  to 
perform  the  operation  ;  the  patient  being  at  the  same  time  firmly 
resolved  to  suffer  any  thing  for  the  chance  of  saving  Jiis  life. 
It  will  be  necessary  to  try  if  the  disease  has  exteuded  as  far  as 
the  articulations,  in  which  case  it  would  be  better  to  ampu- 
tate, than  attempt  to  save  the  limb. 

The  operation  being  decided  on,  the  following  is  the  method 
•to  be  followed.  It  is  commenced  by  laying  bare  the  affedled 
bone  on  the  side  least  covered  with  soft  parts,  and  on  which 
there  will  be  the  least  danger  of  meeting  principal  nerves  and 
■blood-vessels.  Thus  the  inferior  and  external  part  of  the  hu- 
merus is  that  in  v/hich  the  incision  should  be  made  when  this 
bone  is  affe£ted;  when  the  disease  is  seated  in  the  cubitus,  the 
^internal  side  of  the  fore  arm;  and  when  in  the  radius,  its  ex- 
ternal side;  the  lower  part  and  external  side  of  the  tliigh,  when 
the  femur  is  affected;  and  the  anterior  and  internal  side  of  the 
leg,  which  is  covered  by  the  skin  only,  when  the  tibia  is  the 
part  diseased.  This  part  of  the  operation  does  not  consist  of  a 
simple  incision,  but  of  two  semi-elliptic  incisions,  the  parts  be- 
tween which  are  to  be  completely  removed.  This  prat^tice  is  by 
much  preferable  to  the  use  of  caustic,  the  action  of  which  is 
tedious,  and  might  extend  to  the  regenerated  bone,  and  de- 
stroy its  texture.  If  the  patient  be  timid,  caustic  may  be  used, 
but  the  greatest  care  must  be  taken  to  confine  its  action  to  the 
soft  parts.  If  the  hemorrhage  be  great,  and  the  patient's  suf- 
fering intense,  the  wound  may  be  washed,  and  filled  with  lint; 
and  the  rest  of  the  operation  deferred  to  the  following  day. 
After  having  laid  the  bone  bare,  two  or  three  pieces  are  to  be 
cut  out  from  its  inferior  part  by  means  of  a  trepan;  the  inter- 
vals which  separate  the  holes  are  then  forced  out  with  a  chisel 
and  mallet;  and  a  passage  being  thus  opened,  nothing  remaius 
put  to  extract  through  it  the  decayed  boncj  which  is  found  to 


l6'4  OF    CARIES. 

lie  without  any  connexion  in  the  inside.  The  deep  wound  pror 
duced  by  this  operation  is  then  filled  with  lint,  and  dressed  in 
future  like  a  simple  wound,  which  is  to  be  healed  by  suppura- 
tion -,  but  the  recovery  is  always  slow.  If  the  length  of  the  de- 
cayed bone  be  inconsiderable,  the  perforation  may  be  made  in 
the  middle  part  of  the  new  one.  But  when  that  is  not  the 
case  it  will  be  advisable  to  trepan  the  inferior  part  of  the  bone, 
as  a  less  opening  will  suffice  there  than  in  the  middle  part,  and 
as  the  situation  is  more  favourable  for  the  evacuation  of  the 
pus. 

Notwithstanding  the  prodigious  disorganization  and  suppu- 
ration necessarily  attendant  on  this  operation,  it  has  however 
been  followed  with  success  in  some  instances  related  by  David. 

We  are  of  opinion  that  few  cases  occur  in  which  it  is  neces- 
sary to  perform  this  operation;  that  the  reasons  for  undertaking 
it  are  seldom  conclusive;  and  that  it  should  not  be  had  recourse 
to  without  the  maturest  deliberation. 


CHAPTER  XX. 


OF  CARIES. 


THE  more  we  advance  in  the  study  of  diseases  of  the 
bones,  the  greater  is  the  obscurity  in  which  we  find  them 
involved;  and  if  there  be  any  of  them,  the  nature  of  which 
may  be  said  to  be  totally  unknown,  it  is  certainly  that  which  is 
our  present  subject  of  consideration. 

The  clearest  way  in  which  we  can  convey  an  idea  of  caries, 
is,  by  comparing  it  to  those  ill  conditioned  ulcers  of  soft  parts, 
which  are  symptoms  of  a  diseased  state  of  the  system.  But 
the  idea  given  by  this  comparison  is  not  sufficiently  comprehen- 
sive; we  shall  therefore  endeavour  to  supply  its  deficiency  by 
an  exadl  detail  of  the  appearances  of  bones  affected  with  this 
disease. 


OF    CARIES.  165 

Every  part  of  the  osseous  system  is  liable  to  carles  •,  but  it  has 
been  observed,  that  spongy  bones  are  oftener  attacked  by  it 
than  those  that  are  compa£l;  thus  the  vertebra,  astragalus, 
and  other  bones  of  the  tarsus,  those  of  the  carpus,  the  sternum, 
and  the  extremities  of  long  bones,  are  the  most  frequent  seat 
of  this  disease.  For  a  similar  reason  the  bones  of  young  per- 
sons are  more  subjedl  to  it  than  those  of  persons  advanced  in 
life. 

Very  little  information  is  to  be  acquired  by  reading  the  works 
of  the  authors  who  have  treated  of  this  disease.  Almost  all  of 
them  have  confounded  it  wjiia  necrosis,  which  they  termed  dry 
caries  -,  others  have  considered  it  to  be  the  same  as  exostosis.  For 
our  part  we  are  of  opinion  that  there  is  only  one  species  of  this 
disease,  but  that  this  is  susceptible  of  several  modifications. 
The  substance  of  a  bone  afFe£ted  by  it  becomes  so  soft,  that  the 
end  of  a  blunt  probe  may  be  easily  forced  into  it.  The  open- 
ings with  which  the  bone  is  perforated,  are  filled  with  fungous 
flesh,  which  bleeds  from  the  slightest  cause:  there  is  a  dis- 
charge of  a  blackish  serum  from  these  perforations,  which  has 
at  all  times  a  disagreeable  smell,  but  which  is  particularly  fetid 
when  exposed  to  the  conta£l  of  the  air.  Necrosis  and  caries 
differ  in  this  particular  respedl:  in  the  former,  the  bone  affect- 
ed is  entirely  deprived  of  the  vital  principle j  but  in  the  latter 
^his  principle  exists,  and  the  disease  consists  of  a  morbid  aiSlion, 
by  which  the  osseous  texture  is  destroyed. 

The  causes  of  caries  are  distinguished  into  internal  and  ex- 
ternal j  the  internal  are  the  most  frequent,  because  a  contusion 
or  external  violence  is  apter  to  produce  necrosis  than  caries.  It 
may  happen,  however,  that  a  blow  on  a  spongy  bone  shall  oc- 
casion a  caries  of  it,  by  producing  an  extravasation  of  blood  or 
medullary  juice,  which  cannot  be  afterwards  taken  into  the 
system  by  absorption. 

Abscesses  are  said  to  occasion  sometimes  a  caries  of  the 
bones,  over  which  they  take  place;  and  we  are  toid,  that  the 
existence  of  the  morbid  state  of  the  bone  may  be  ascertained 
by  introducing  a  probe  to  the  bottom  of  the  abscess. 

Conformably  to  this  theory,  it  has  been  laid  down  as  a  rule, 
that  abscesses  situated  over  bones  should  be  opened  at  an 
early  period,  in  order  to  prevent  any  disorder  of  the  bone  or 
periosteum  from  the  stagnation  of  the  purulent  matter.  But  if 
abscesses  formed  over  certain  bones,  as,  for  instance,  over  the 
anterior  face  of  the  tibia,  or  mastoid  process  of  the  temporal 
bone,  be  frequently  accompanied  with  caries,  the  latter  is  the 


l66  OF    CARIES. 

cause,  and  not  a  consequence,  of  the  abscess.  Pus,  which  is  a 
bland,  un(5tuous,  and  inodorous  fluid,  never  attacks  the  soft 
parts  with  which  it  is  in  conta<5l,  until  its  qualities  are  changed 
by  exposure  to  the  air.  When  an  abscess  forms  in  the  anteri- 
or part  of  the  parietes  of  the  abdomen,  the  peritoneum  of  that 
part,  naturally  a  thin  membrane,  instead  of  being  corroded, 
beconies  thick  and  strong  enough  to  resist  the  effusion  of  the 
pus  into  the  cavity  of  the  abdomen.  The  periosteum  becomes 
thickened  in  similar  circumstances,  when  the  abscess  is  a  con- 
sequence of  an  external  injury. 

We  may  conclude,  then,  that  caries  is  seldom  produced  by 
an  external  cause;  and  that  most  frequently  a  blow  or  external 
injury,  wh-en  followed  by  that  disease,  has  adled  only  as  an 
exciting  cause,  z  disposition  to  it  having  pre-existed.  There 
is  every  reason  to  believe  that  it  may  be  ascribed  in  almost  all 
cases  to  a  disease  of  the  system,  such  as  scrofula,  lues,  scurvy, 
or  even  cancer. 

Scurvy  diminishes  the  energy  of  the  contra^ile  fibre,  and 
diffuses  a  principle  of  dissolution  in  the  solids  and  fluids.  Tfie 
blood  rendered  more  fluid  by  it  than  natural,  oozes  through 
the  pores  of  its  small  vessels:  spots  or  ecchymoses  manifest 
themselves,  first  in  the  parts  in  which  the  circulation  is  most 
languid,  as  on  the  hands  and  feet:  the  muscles  become  soft  and 
painful;  the  gums  swell,  and  separate  from  the  alveolar  pro- 
cess: the  periosteum  may  become  tumefied  in  like  manner, 
and  lose  its  connexion  with  the  bone  affe£ted  with  caries. 

Scrofula  attacks  the  spongy  part  of  bones  and  the  lymphatic 
system.  A  caries  from  this  cause  is  very  frequent  in  the  tarsus, 
carpiis,  elbow,  and  knee;  but  k  is  ahvays  preceded  by  a  white 
swelling. 

The  venereal  disease  is  sometimes  a  cause  of  caries,  though 
its  adtion  on  the  osseous  system  more  generally  produces  ne- 
crosis or  exostosis.  However,  when  it  attacks  the  bones  of  the 
nose,  it  produces  a  caries  of  them,  by  which  they  are  consu*- 
med,  and  the  face  sadly  disfigured.  The  bones  of  the  palate 
are  sometimes  destroyed  in  the  same  manner,  and  by  the  same 
cause. 

In  cancers  of  the  mammae,  the  sides  of  the  sternum  are  of- 
ten found  carious;  which  proves  that  cancerous  ulcers  may, 
as  well  as  the  preceding  diseases,  occasion  a  cai-ies  of  the  bones 
in  their  neighbourhood. 

Nothing  can  be  easier  than  to  ascertain  the  existence  of  a 
superficial  caries;  and  when  the  affedled  bone  is  deep-seated. 


OF    CARIES.  167 

it  may  be  discovered  by  introducing  a  probe;  for  if  the  bone 
be  cariour,.the  probe  may  be  easily  forced  into  its  substance. 
But  bones  which  we  cannot  readily  come  at  may  be  carious,  in 
which  case  the  diagnosis  is  somewhat  more  difficult*,  however, 
if  a  fistula,  from  which  a  fetid  blackish  matter  flows,  be  dire£l- 
ed  towards  a  bone,  and  if  the  surrounding  soft  parts  be  at  the 
same  time  turgid  and  indurated,  there  is  every  reason  to  appre- 
hend a  caries.  The  black  colour  of  the  discharge  is,  however, 
equivocal  j  because,  as  remarked  by  Ambrose  Pare,  it  may  be 
occasioned  by  a  bit  of  agaric  or  other  foreign  body  introduced 
into  the  wound.  It  will  be  prudent,  therefore,  in  dubious  cases, 
to  trust  chiefly  to  the  history  of  the  disease. 

If  a  person  aiFeO:ed  with  a  certain  constitutional  disease,  feel 
deep-seated  and  acute  pains  in  any  of  his  bones  ;  and  if  the 
pained  part  swell,  and  become  the  seat  of  an  abscess,  from 
which  a  purulent  matter  of  a  bad  quality  flows,  there  is  every 
reason  to  believe  that  the  bone  afl'ecSted  with  pain  is  carious. 
Inert  abscesses  are  attended  with  nearly  the  same  symptoms, 
with  this  difi^erence,  that  they  are  not  preceded  by  pain.  Ca- 
ries occasioned  by  syphilis  affecSVs  most  commonly  the  tibia,  os 
frontis,  ossa  nasi,  ossa  palati,  and  sternum.  Whenever,  there- 
fore, any  of  these  bones  become  carious,  whilst  the  person  la- 
bours under  syphiHs,  there  is  just  ground  for  concluding  that 
the  caries  is  a  symptom  of  the  venereal  affe<Slion. 

A  caries  of  the  vertebrae  is  known  by  peculiar  symptoms, 
among  which  a  paralysis  of  the  inferior  extremities,  and  the 
formation  of  abscesses  in  the  groin,  verge  of  the  anus,  or  lum- 
bar region,  are  the  most  remarkable. 

The  prognosis  is  more  unfavourable  in  cases  of  caries  of  spon- 
gy bones,  than  in  those  of  a  similar  affection  of  compadt  ones, 
thus  there  is  not  so  muc"h  to  be  apprehended  when  the  bones 
of  the  cranium  or  the  scapulce  are  atTefted,  as  when  the  extre- 
mities of  long  bones  are  similarly  diseased.  Caries  of  the 
bones  of  the  carpus  and  tarsus  is  also  very  dangerous.  The  evil, 
en  account  of  these  bones  being  in  such  close  contact,  extends 
from  one  to  the  other;  and  when  one  of  them  becomes  carious, 
it  is  very  difficult  to  stop  the  progress  of  the  disease  without  am- 
putating the  limb. 

This  operation  is  often  the  only  resource  in  our  power 
against  caries  of  short  bones,  or  of  the  extremities  of  long 
ones;  and  we  are  even  deprived  of  this  when  the  bone  afFeiSted 
with  it  is. deep-seated:  thus  caries  of  the  head  of  the  femur, 
or  of  the  cotyloid  cavity,  cannot  be  remedied  by  thi«  operati- 


l68  Oi*    CARIES. 

on.  The  same  may  be  said  of  caries  of  the  spine,  also  named 
gibbosity,  in  which,  as  well  as  in  the  preceding  case,  our 
treatment  must  be  merely  palliative. 

Caries  from  an  external  cause  is  less  dangerous  as  well  as  less 
frequent  than  that  from  an  internal;  and  that  resulting  from 
an  internal  disposition  is  much  more  dangerous  when  it  pro- 
ceeds from  a  scrofulous  or  cancerous  diathesis,  than  from  a  ve- 
nereal or  scorbutic;  for  some  efficacious  remedies  against  the 
latter  are  known;  but  cancer  and  scrofula  resist  all  the  reme- 
dies with  which  we  are  as  yet  acquainted.  It  is  also  more  dan- 
gerous to  old  than  to  young  persons,  not  that  its  progress  is 
not  more  rapid  in  the  latter,  as  already  mentioned,  but  because 
nature  is  more  capable  of  limiting  its  ravages  in  youth  than  in 
old  age.  Finally,  the  prognosis  is  further  influenced  by  the 
extent  of  the  disease,  the  patient's  strength,  and  state  of  the 
neighbouring  soft  parts. 

There  is,  perhaps,  no  disease  in  which  the  indications  of 
cure  are  more  vague  than  in  caries,  and  none  in  which  the 
treatment  is  less  regular.  The  ancients  prescribed  unftuous  or 
relaxing  applications,  but  they  preferred  acrid  irritating  sub- 
stances, such  as  the  powder  of  euphorbium,  tindlure  of  aloes 
and  myrrh,  oil  of  turpentine,  mineral  acids,  caustic  alkali,  or 
even  the  aclual  cautery.  Monro,  Tenon,  and,  in  imitation  of 
them,  some  modern  practitioners,  have  preferred  the  use  of 
unftuous  and  emollient  applications;  but,  in  order  to  discover 
the  preferable  mode  of  treatment,  it  is  necessary  to  take  a 
close  view  of  the  evil  against  which  it  is  to  be  directed.  We 
must  then  consider,  that  a  bone  a£Fe6led  with  caries  is  a  prey 
to  a  morbid  action  of  its  own  parts,  and  that  this  acStion  creeps 
from  one  part  to  another,  and  pervades  the  whole  with  great- 
er or  less  rapidity,  if  art  does  not  come  to  the  assistance  of  na- 
ture to  arrest  its  progress. 

If  the  caries  be  produced  by  some  affection  of  the  system, 
this  should  be  ascertained  and  combated  with  appropriate  re- 
medies. Thus  the  use  of  mercurial  and  sudorific  medicines  ar- 
rests the  progress  of  caries  proceeding  from  the  venereal  dis- 
ease, and  aids  nature  in  separating  the  unsound  from  the  sound 
part.  The  use  of  spirituous  drinks,  vegetable  diet,  and  aeids, 
removes  at  once  scurvy  and  the  caries,  to  which  it  had  given 
rise,  &c.  &c.  But  if  it  has  been  occasioned  by  an  external 
cause,  or  if  it  has  remained  after  the  internal  one  has  been  re- 
moved, so  as  to  be  reduced  to  the  state  of  a  mere  topical  af- 
fection, its  progress  may  be  arrested,  and  the  separation  of  the 


OF    CARIES.  169 

diseased  parts  facilitated  by  the  use  of  such  substances  as  stimu- 
late the  parts,  or  such  as  absorb  and  neutralize  the  fluids  which 
tend  to  propagate  the  morbid  adlion.  Thus  the  desiccation  of 
a  carious  ulcer  has  been  effected  by  the  use  of  an  absorbing 
powder  and  pledgets  of  lint  that  had  been  dipped  in  tindlure  of 
aloes  and  myrrh. 

If  these  remedies  be  found  ineffectual,  recourse  must  be  had 
to  more  active  ones;  a  pledget  of  lint  dipped  in  a  solution  of  ni- 
trate of  silver,  may  be  applied  on  the  carious  part,  and  renewed 
every  day.  This  portion  of  the  bone  is  by  this  means,  quickly 
dried  up,  and  reduced  to  the  state  of  a  simple  necrosis;  the  pro- 
pagation of  the  morbid  a£lion  is  arrested,  and  nature  effefts  a 
separation  of  the  diseased  parts.  It  will  not  be  amiss,  however, 
to  move  frequently  the  dried  piece,  and  it  may  be  necessary  to 
prevent  the  fungous  flesh  from  spreading  so  as  to  impede  the 
exfoliation.  The  ulcer  heals  after  the  exfoliation  has  taken 
place,  and  the  cicatrix  is  more  or  less  deep,  and  of  a  red  co- 
lour, not  blackish  and  livid,  as  a  cicatrix  formed  over  a  dis- 
eased bone. 

If  the  caries  be  very  humid,  that  is,  if  a  great  quantity  of 
sanies  flow  from  it,  these  remedies  even  the  murcurial  nitrate, 
will  be  of  no  effedt.  The  sanies  washes  the  pledget,  and  di- 
lutes the  caustic  so  much,  that  its  aftion.is  considerably  en- 
feebled. Caustic  pot-ash  would  be  subject  to  the  same  incon- 
venience. In  these  cases,  the  a£lual  cautery  is  a  remedy  to  be 
preferred  to  all  others:  by  its  action  the  carious  part  is  in  an 
instant  reduced  to  the  state  of  an  inorganic  dry  substance,  and 
the  caries  thus  converted  into  necrosis.  This  remedy  is  appli- 
cable to  every  case  of  humid  caries  where  the  surrounding  soft 
parts  have  not  a  manifest  tendency  to  cancer.  Sometimes, 
however,  the  soft  parts  surrounding  a  carious  bone  have  that 
tendency  in  so  advanced  a  degree,  that  the  acStual  cautery 
would  necessarily  occasion  the  developement  of  that  morbid 
state.  The  general  rules  to  which  the  use  of  the  aftual  caute- 
ry may  be  reduced  are  as  follow: 

In  the  first  place,  all  the  carious  part  of  the  bone  must  be 
laid  bare,  whether  by  cutting  away  the  soft  parts,  or  destroy- 
ing them  by  caustic.  The"  latter  method  being  tedious,  incon- 
venient and  uncertain,  should  not  be  used  unless  when  the  pa- 
tient will  not  submit  to  the  use  of  the  knife.  The  bone  being 
in  this  manner  laid  bare  and  scraped,  the  surgeon  provides  him- 
self with  several  cauterizing  irotis  of  the  same  form,  because 
the  application  of  one  is  seldom  suflicient.  It  will  also  be  ne- 
22 


lyO  OF    CARIES. 

cessary  to  provide  a  number  of  canulx  when  the  cautery  is  t9 
be  applied  on  a  bone  from  about  which  the  soft  parts  cannot 
be  completely  raised,  as,  for  instance,  on  the  os  coccygis,  or 
sacrum:  by  means  of  these  canulae,  the  hot  iron  can  be  intro- 
duced without  injuring  the  soft  parts.  In  every  case  it  will  be 
necessary  to  protect  the  surrounding  parts  as  much  as  possible 
from  the  a£tion  of  the  cautery. 

The  iron,  whatever  may  be  its  size,  should  be  heated  white, 
as  the  hotter  it  is  the  more  rapid  and  less  painful  is  its  aiStion. 
On  the  instant  of  its  application,  a  black  thick  smoke  rises 
from  the  surface  of  the  burning  bone,  the  smell  of  which  re- 
sembles exactly  that  of  burning  horn:  the  great  quantity  of 
sanies  quickly  diminishes  the  heaf,  for  which  reason  a  second 
is  to  be  immediately  applied  with  the  same  precautions;  and  a 
third,  if  the  two  preceding  have  not  burned  deep  enough.  Care 
should  be  taken  to  extirpate  the  disease  by  burning  every  part 
that  is  affe£ted;  and  if  the  use  of  the  cautery  has  not  always 
had  the  success  expected  from  it,  the  failure  of  it  is  to  be  attri- 
buted to  the  timidity  of  the  operator.  A  carious  bone  becomes 
worse  by  the  application  of  the  a£lual  cautery,  if  the  evil  be 
not  entirely  rooted  out;  just  as  a  cancerous  tumour  becomes 
irritated,  and  makes  a  more  rapid  progress,  if  imperfectly  cau- 
terized. 

The  a£lual  cautery  a£ls  by  evaporating  the  noxious  fluids  in 
which  the  carious  bone  was  immersed;  by  changing  the  caries 
into  necrosis,  and  by  irritating  the  subjacent  sound  parts,  and 
exciting  that  a£Vion  of  the  vessels  by  which  the  dead  part  of 
the  bone  must  be  thrown  off". 

It  is  almost  superfluous  to  remark  here,  that  this  operation 
cannot  be  undertaken  with  any  hopes  of  success,  if  the  inter- 
nal cause  of  the  caries  still  exist. 

Let  us  examine,  in  the  next  place,  the  modifications  of  this 
general  treatment,  which  may  be  required  for  any  particular 
bone. 

The  bones  of  the  cranium  are  often  afl"e^ed  with  the  vene- 
real caries,  of  which  pain  and  tumefa6lion  of  the  part  are  the 
first  symptoms.  The  tumour  augments  and  becomes  soft,  and 
on  bursting  spontaneously,  or  being  opened  by  an  instrument, 
a  thin,  serous,  purulent  matter  flows  from  it.  If  a  probe  be 
now  introduced  into  the  wound,  the  bone  will  be  found  to  be 
carious.  The  first  remedies  must,  in  this  case,  be  diredled 
against  the  disease  of  the  system.  The  use  of  caustics  is  en- 
tirely inadmissible;  for  should  their  action  extend  too  far,  the 


or  CARIES.  171 

worst  consequences  might  result  from  it,  such  as  inflammation 
of  the  brain  or  its  meaibranes.  It  is  better  to  remove  the  dis- 
eased part  of  the  bone  by  means  of  a  trepan.  In  laying  the 
bone  bare,  as  much  of  the  integuments  should  be  preserved  as 
will  be  sufficient  to  cover  the  wound,  which  precaution  will 
accelerate  the  cure. 

It  is  particularly  in  caries  of  the  mastoid  portion  of  the  tem- 
poral bone  that  the  use  of  the  cautery  is  admissible.  Abscesses 
are  frequently  formed  in  consequence  of  caries  in  that  part  of 
the  bone;  these  burst,  and  their  openings  degenerate  into  fis- 
tulae.  If  a  carious  state  of  the  bone  be  discovered  by  the  in- 
troduiflion  of  a  probe,  the  bone  is  to  be  laid  bare,  and  the 
cautery  applied,  and  repeated  until  the  caries  is  completely  de- 
stroyed. The  mastoid  portion  of  the  temporal  bone  is  spongy 
in  its  texture,  and  sufficiently  thick  to  prote£l  the  brain  and 
its  membranes  from  the  action  of  the  cautery.  Tenon  and 
Chopart  pradlised  this  operation  with  success. 

The  bones  of  the  face,  and  those  of  the  nose  and  palate, 
are  very  subject  to  the  venereal  caries;  but  this  affi.^(n:ion  of 
them  disappears  by  removing  the  general  disease  of  the  sys- 
tem. The  parts,  however,  remain  deformed  in  consequence 
of  the  loss  of  substance; 

The  colledlion  of  matter  which  frequently  takes  place  in  the 
antra  maxiliaria  sometimes  occasions  a  caries  of  the  bones 
v/hich  form  these  cavities.  In  these  cases,  all  that  is  necessa- 
ry is  to  perforate  into  the  cavjty  through  the  alveolar  process; 
for  as  soon  as  the  collected  matter  gets  a  free  passage,  the  fistu- 
las, if  any  have  been  formed  externally,  dry  up,  the  carious 
part  of  the  bone  separates  and  comes  away,  and  the  wound  in 
the  soft  parts  heals  at  the  same  time. 

The  caries  of  the  os  unguis,  which^is  sometimes  complica- 
ted with  fistula  lachrymalis,  is  remedied  by  the  different  ope- 
rations performed  for  giving  a  free  passage  to  the  tears.  The 
scorbutic  caries  of  the  alveolar  process  is  removed  by  the  same 
remedies  as  the  general  disease. 

As  soon  as  the  system  is  perfe6lly  clear  of  the  scorbutic  dia- 
thesis, the  bone  exfoliates,  and  the  gums  acquire  their  natural 
firmness.  Detersive  gargles  may  be  used  to  accelerate  this  ter- 
mination. 

Caries  of  the  spine  is  attended  with  much  worse  consequen- 
ces; the  gibbosity  and  secondary  abscesses  of  which  it  is  the 
cause,  generally  prove  fatal.  When  the  anterior  part  of  any 
of  the  vertebroe  becomes  afFe^Sled  with  caries  in  consequence  of 


172  OF    CARIES. 

a  diseased  state  of  the  system,*  the  purulent  matter  that  is 
formed  makes  its  way  into  the  cellular  texture  which  lines  the 
anterior  part  of  the  spine,  and  descends  by  its  own  weight 
along  the  vessels  to  the  superior  part  of  the  pelvis;  whence  it 
sometimes  flows  along  the  external  iliac  arterv  into  the  groin, 
where  it  forms  a  tumour.  At  other  times  it  descends  into  the 
pelvis  along  the  hypogastric  vessels,  and  forms  tumours  about 
the  anus;  finally,  it  may  penetrate  through  the  fibres  of  the 
lumbar  paries  of  the  abdom.en,  and  manifest  itself  at  the 
posterior  part  of  the  pelvis.  These  accumulations  of  pus,  or 
symptomatic  abscesses,  are  always  preceded  for  a  longer  or 
shorter  time,  by  pain  in  some  part  of  the  spine;  and  the  tu- 
mour forms  without  any  antecedent  or  co-existing  inflamma- 
tion of  the  part.  The  abscess  acquires  insensibly  an  enormous 
volume,  and  the  pus  makes  its  way  into  the  cellular  texture  of 
the  limb  of  the  afi'edled  size:  its  side  may,  however,  be  dimi- 
nished by  compression,  and  its  contents  seem  to  retreat  into 
the  abdomen.  Tiie  integuments  inflame  at  length,  and  burst 
in  the  most  proje<5ting  point;  a  thin  purulent  matter  flows  from 
the  opening;  it  is,  at  first  perfectly  inodorous,  hat  soon  ac- 
quires a  fetid  smell,  and  changes  colour.  This  alteration  in 
the  qualities  of  the  pus  seems  to  be  owing  to  the  contact  of  the 
air;  but  so  great  is  its  fetidness,  that  the  patient's  existence  is 
loathsome  to  himself,  and  insupportable  to  others:  the  absorp- 
tion of  this  matter  brings  on  slow  fever,  diarrhoea,  colliquative 
sweats,  and  marasmus,  and  the  patient  is  at  length  cut  off.  As 
the  fatal  event  is  distant  in  proportion  to  the  retardation  of  the 
opening  of  the  abscess,  and  to  its  prote£lion,  when  opened, 
from  the  contact  of  the  air,  it  is  evident  that  it  should  not  be 
opened  as  long  as  it  can  be  avoided;  and  that  when  it  becomes 
absolutely  necessary,  the  opening  should  be  as  small  as  possi- 
ble, and  the  air  carefully  excluded.  Both  these  purposes  are 
answered  by  making  the  opening  with  a  seton  needle,  and 
leaving  the  seton  in  the  abscess;  but  as  this  is  not  the  pro- 
per place  to  give  a  full  account  of  the  treatment  of  these  ab- 
scesses, we  shall  proceed  to  the  consideration  of  that  affe<Slion 
of  the  spine  which  has  been  termed  gibbosity. 

This  affection  does  not  always  depend  on  a  caries  of  the  ver- 
tebrae; and  when  it  arises  from  that  cause,  the  caries  is  then  of 
a  peculiar  nature,  being  almost  dry,  and  unattended  with  the 

•  Masturba^Ion  is  frequently  a  cause  of  tliis  caries,  Citizen  Boyei's 
pra£lice  has  furnished  him  wjih  many  examples  ot  it. 


OF    CARIES.  173 

formation  of  abscesses.  The  affected  vertebra,  filled  with  holes, 
and  as  if  moth-eaten,  yields  to  the  incumbent  weight;  the  body 
of  that  which  is  superior  to  it  descends,  while  its  spinous  pro- 
cess ascends  and  projects  under  the  integuments.  A  never-fail- 
ing symptom  of  this  disease  is  a  paralysis  of  the  inferior  extremi- 
ties, rectum,  and  bladder.  If  the  derangement  take  place  in  the 
vertebrae  of  the  neck  ^^ which  is  very  rare),  the  patient  is  soon 
destroyed  in  consequence  of  the  paralysis  of  the  muscles  by 
which  respiration  is  performed.  When  the  derangement  of  the 
vertebra  is  gradual,  the  progress  of  the  caries  being  slow,  a 
numbness  is  first  felt  in  the  lower  extremities,  which  is  the  pre- 
cursor of  paralysis:  but  the  bladder,  redlum,  and  inferior  ex- 
tremities, soon  become  paralytic,  and  the  patient  is  confined  to 
his  bed  until  relieved  by  death.  Gibbosity  from  this  cause  is 
fatal  to  adult  persons.  That  observed  in  young  children  is  dif- 
ferent in  its  consequences,  and  seems  to  proceed  from  a  diffe- 
rent cause-,  that  is,  from  a  collapse  of  the  vertebrae  before  they 
have  acquired  their  full  consistence,  rather  than  from  a  carious 
affe6lion.  In  cases  of  this  kind,  a  perfeft  recovery  has  been  ef- 
fedled  by  applying  caustic  to  the  sides  of  the  tumour,  by  burning 
moxa,  or  rubbing  irritating  substances  on  the  spine,  and  by 
joining  to  these  means  the  use  of  the  cold  bath  and  a  tonic  re- 
gimen. 

When  the  same  person  is  at  once  affeifled  with  gibbosity  and 
secondary  abscesses,  there  is  no  chance  of  his  recovery. 

Enough  has  been  said  to  shew  the  extreme  danger  of  caries 
of  the  spine,  and  the  insufficiency  of  art  in  the  treatment  of  it. 
The  spongy  texture  of  the  sternum  renders  it  very  liable  to 
be  effe<Sted  with  caries,  the  progress  of  which  is,  for  the  same 
reason,  more  rapid  in  it  than  in  any  other  bone.  The  soft  parts 
which  cover  the  carious  portion  of  bone,  become  inflamed,  and 
abscesses  form,  which  burst  in  a  little  time.  The  state  of  the 
bone  may  now  be  discovered  by  introducing  a  probe  through 
one  of  these  openings;  and  very  often,  besides  the  caries,  it  is 
found  that  an  effusion  of  pus  has  taken  place  into  the  anterior 
part  of  the  mediastinum.  In  which  cases  .he  probe  penetrates 
more  or  less  into  the  cavity  of  the  thorax,  and  the  pus  con- 
stantly flows  in  greater  or  less  quantity  through  the  fistula :  it 
most  frequently  happens  that  the  stagnation  of  the  pus,  the  mor- 
bid changes  which  it  undergoes,  and  the  effects  of  its  absorption 
in  this  state  into  the  system,  render  it  necessary  to  apply  the 
trepan  to  the  sternum.  Among  the  bad  consequences  of  caries 
of  the  sternum,  may  be  reckoned  the  destruction  of  a  part  of 


174  OF    CARIES. 

the  pleura,  or  even  of  the  pericardium:  although  in  the  great- 
er number  of  cases  the  former  of  these  membranes  becomes 
thicker  in  the  part  corresponding  to  the  abcess,  and  sometimes 
cartilaginous,  or  even  bony.  The  pulsation  of  the  heart  be- 
comes very  manifest  by  the  destruction  of  the  pericardium. 
Harvey  profited  of  a  case  of  this  nature  to  shew  this  phenome- 
non to  the  King  of  England,  and  several  other  persons.  But 
whether  the  thickening  of  a  part  of  the  pleura,  or  the  destruc- 
tion of  a  portion  of  the  pericardium,  be  the  consequence  of  the 
abscess,  the  cavity  of  the  thorax,  properly  so  called,  is  not 
opened  in  either  case. 

The  treatment  of  caries  of  the  sternum  varies  according  to 
the  circumstances  of  the  case ;  it  may  be  remarked  however, 
that  the  particular  structure  of  the  bone  renders  a  caries  of  it 
extremely  dangerous.  A  spontaneous  recovery  is  scarcely  to  be 
expected,  although  the  following  case  furnishes  an  instance  of 
it.  A  person  convalescent  from  another  disease,  was  suddenly 
seized  with  an  acute  pain  behind  the  sternum;  respiration  be- 
came difficult,  and  a  fever  supervened.  At  length  a  tumour, 
■with  fludluation,  manifested  itself  a  little  lower  than  the  middle 
part  of  the  bone.  A  small  portion  of  caustic  pot  ash  was  applied 
to  this  tumour;  and  on  dividing  the  crust  formed  by  it,  a  great 
quantity  of  the  pus  flowed  out  and  the  patient  felt  much  re- 
lieved. After  opening  the  abscess,  the  suppuration  gradually 
diminished,  and  the  fistulous  orifice  was  closed  up  in  th^  space 
cf  a  few  months;  during  which  time  however,  the  patient  re- 
sided in  the  country,  and  used  a  nourishing  diet  and  tonic  me- 
dicines. It  ought  to  be  remarked,  that  it  is  possible  that  the 
abscess  may  not,  in  this  case,  have  proceeded  from  a  caries  of 
the  sternum;  and  that  the  pus  collected  in  the  anterior  medias- 
tinum may  have  made  its  way  outward  through  the  opening 
which  is  often  found  in  this  part  of  the  sternum. 

The  treatment  of  caries  of  the  sternum  does  not  differ  from 
that  which  has  been  already  generally  described.  Particular 
care  must  be  taken  however,  that  in  applying  caustics,  their 
influence  may  not  extend  to  the  organs  of  respiration.  But 
when  instead  of  caustics,  cutting  instruments  ai-e  used,  the  part 
affected,  however  extensive,  should  be'  totally  removed.  This 
operation  is  not  attended  with  great  danger,  because  the  inter- 
nal mammary  artery,  if  opened,  can  be  easily  taken  up.  After 
the  bone  has  been  removed,  the  pleura,  corresponding  to  the 
empty  space,  will  be  found  to  thicken  in  that  part,  and  to  ac- 
quire a  cartilaginous  hardness,  so  as  to  replace,  in  some  degree^ 


OF    CARIES.  175 

the  bone  which  has  been  destroyed.  However,  after  the 
wound  is  completely  healed,  it  will  be  prudent  to  cover  the 
part  with  a  piece  of  pasteboard  or  leather.  If  the  carious  part 
cannot  be  totally  removed,  it  will  be  necessary  to  make  two 
perforations  in  the  lower  part  of  the  sternum,  in  order  to  give 
a  free  passage  to  the  purulent  matter.  Though  the  disease  will 
not  be  radically  removed  by  this  means,  yet  the  sufferings  of 
the  patient  will  be  considerably  alleviated. 

Caries  of  the  ribs,  or  that  of  the  bones  of  the  pelvis,  offers 
nothing  particular,  it  is  to  be  remarked,  however,  that  when 
the  posterior  ends  of  the  ribs,  or  the  anterior  face  of  the  sa- 
crum, are  affefted,  secondary  abscesses  may  take  place  as  in  si- 
milar affeftions  of  the  vertebrae.  Caries  of  the  sacrum  often 
succeed  a  gangrene  of  the  soft  parts  which  cover  its  convex 
side:  in  which  case  it  will  be  necessary  to  wait  a  spontaneous 
exfoliation;  or  if  nature  does  not  appear  adequate  to  that  ope- 
ration, and  if  a  great  quantity  of  fungous  flesh  be  found  to 
grow  up  through  the  carious  bone,  it  will  be  necessary  to  apply 
the  adtual  cautery,  according  to  the  rules  already  laid  down. 
Liquid  caustics  are  improper  in  this  case,  because  by  passing 
the  large  cancelli,  they  might  penetrate  to  the  sound  parts  of 
the  bone,  and  occasion  a  necrosis  of  it. 

Caries  of  the  different  parts  of  the  iliac  bone,  and  particu- 
larly of  the  cotyloid  ctivity,  shall  be  treated  of  in  the  article 
on  secondary  or  spontaneous  luxation  of  the  femur. 

Caries  of  the  extremities  of  long  bones,  as  it  usually  accom- 
panies white  swellings  of  the  articulations,  will  be  considered 
in  treating  of  the  latter  affeilions. 


176 


CHAPTER  XXI. 


OF  EXOSTOSIS. 

A  SWELLING  may  take  place  in  bones  as  well  as  in 
other  parts,  from  a  determination  and  accumulation  of 
fluids;  but  there  is  a  particular  kind  of  tumour  which  forms 
on  their  surface,  and  which  is  denominated  exostosis.  This 
name,  however,  comprehends  different  species,  which  should 
be  considered  as  distincflj  thus  that  affedlion  which  has  been 
described  under  the  name  of  spina  ventomy  or  osteosarcoma^  is  a 
distinct  disease:  there  is  also  another  species  of  exostosis  diffe- 
rent from  all  others,  and  which  consists  principally  in  a  thick- 
ening and  tumefaction  of  the  periosteum;  it  may  very  proper- 
ly be  termed /j^nW/oj-zV.  Exostosis,  properly  so  called,  is  rare, 
the  reason  of  which  is  easily  perceived  from  the  consideration 
of  the  hardness  and  consistence  of  the  texture  of  the  bones, 
the  small  number  of  their  vessels,  and  consequently  the  diffi- 
culty of  a  copious  influx  of  humours  into  them. 

The  tumefied  portion  of  bone  acquires  in  some  cases  such  a 
hardness,  that  no  remains  of  a  fibrous  strudlure  can  be  distin- 
guished in  it,  and  it  absolutely  resembles  ivory;  in  other  cases 
it  is  spongy;  and  finally  it  may  be  composed  of  osseous  and 
fleshy  parts;  this  latter  variety  resembles  very  much  spina  ven- 
tosa. 

The  bones  most  frequently  affefled  with  exostisis  are  the 
broad  bones  of  the  head,  the  lower  jaw,  sternum,  humerus, 
radius,  cubitus,  the  bones  of  the  carpus,  the  femur,  and  tibia. 
There  is,  however,  no  bone  of  the  body  which  may  not  be- 
come the  seat  of  this  disease,  and  the  affeftion  may  extend  to 
a  greater  or  less  portion  of  it.  It  is  not  uncommon  to  find  the 
broad  bones  of  the  cranium  affected  with  exostosis  in  their 
whole  extent;  the  ossa  parietalia,  for  instance,  sometimes  ac- 
quire an  inch  in  thickness  from  this  morbid  affedlion. 

In  most  cases,  however,  tKe  exostosis  rises  from  the  surface 
of  the  bone,  and  manifests  itself  as  a  hard  round  tumour.  It 
sometimes  appears  towards  the  extremities  of  long  bones,  and 


OF    EXOSTOSIS.  177 

at  other  times,  more  or  less,  near  their  middle  part;  and  it  is 
reiiarked  that  exostosis  originating  from  a  venereal  cause  arc 
found  principally  on  compadt  bones,  and  such  of  these  as  are 
but  lightly  covered  with  soft  parts,  as  those  of  the  cranium 
and  face,  and  the  tibia  at  its  internal  side;  whilst,  on  the  con- 
trary, those  arising  from  a  scrofulous  diathesis  appear  on  the 
spongy  extremities  of  long  bones,  and  on  short  ones  of  a  simi- 
lar texture.  These  two  diseases  are  almost  the  sole  causes  of 
this  topical  affedlion  of  the  bones.  A  cancerous  or  scorbutic 
diathesis  seldom  occasions  it.  They  more  commonly  produce 
caries,  by  effedting  a  separation  of  the  periosteum  from  the 
bone.  It  must  be  remarked,  however,  that  exostosis  and  ca- 
ries have  the  greatest  aiSnity  with  one  another;  as  is  evident 
from  the  greater  part  of  exostoses  terminating  in  caries.  J.  L. 
Petit  pointed  out  this  analogy  by  a  detailed  comparison  of  the 
two  diseases.  The  conversion  of  exostosis  into  caries  takes 
place  particularly  in  spongy  bones,  and  in  persons  affefted  with 
scrofula.     The  ivory  exostosis  never  terminates  in  caries. 

Exostosis  proceeds  very  rarely  from  an  external  cause,  such 
as  a  contusion,  though  such  a  consequence  is  not  imposdble. 
In  most  cases  it  is  produced  by  an  internal  disease,  and  princi- 
pally by  lues  venerea,  or  scrofula,  as  already  mentioned. 

An  enlargement  of  the  extremities  of  long  bones,  that  of 
the  whole  substance  of  short  ones,  joined  to  a  swelling  of  the 
glands  of  the  neck,  a  delicacy  and  whiteness  of  the  skin,  a 
fulness  of  the  face,  and  tumefadlion  of  the  point  of  the  nose 
and  upper  lip,  are  marks  of  a  scrofulous  diathesis. 

The  osseous  system  is  attacked  by  the  venereal  disease  only 
in  the  advanced  stages  of  that  disorder.  The  formation  of  ex- 
ostoses from  this  cause  is  generally  preceded  by  dull  pains, 
which  appear  to  be  deep-seated,  and  which  are  generally  most 
severe  during  the  night. 

An  exostosis  is  always  hard,  but  varies  in  size,  and  may  be 
indolent  or  painful.  By  these  marks,  and  by  its  firm  adhesion 
to  the  bone,  it  may  be  always  distinguished  from  every  other 
kind  of  tumour.  But  if,  on  the  contrary,  the  enlargement 
takes  place  in  a  short  bone,  and  if  its  hardness,  though  consi- 
derable, be  somewhat  less  than  that  just  described,  on  which 
the  finger  can  make  no  impression,  it  is  probably  a  periostosis; 
which  is  by  no  means  an  uncommon  symptom  of  the  venereal 
disease.  It  is  sometimes  impossible  to  ascertain  the  existence 
of  an  exostoses  before  the  patient's  death  •  such  was  the  case  of 
an  individual  whose  parietal  bone  had  been  found,  after  death, 
23 


178  OF    EXOSTOSIS. 

to  be  three  times  thicker  than  natural.  A  similar  case  is  rela- 
ted in  the  Memoirs  of  the  Academy  of  Dijon.  In  this  instance 
the  person  died  from  an  exostosis  on  the  internal  side  of  the 
OS  pubis,  whieh  by  pressing  on  the  neck  of  the  bladder  pre- 
vented the  passage  of  the  urine,  or  the  introduflion  of  a  ca- 
theter. 

It  is  possible  that  the  head  of  a  luxated  bone  may  be  mista- 
ken for  an  exostosis:  this  was  the  case  with  a  young  man 
whose  clavicle  was  dislocated  at  that  end  of  it  attached  to  the 
sternum.  The  tumour  formed  by  the  end  of  the  displaced 
bone,  was  mistaken  for  an  exostosis,  and  was  treated  as  such; 
but  the  incfficacy  of  the  treatment  induced  the  patient  to  ap- 
ply to  Desault,  then  head  surgeon  of  La  Charite.  This  prac- 
titioner recognized  instantly  the  luxation  outward  of  the  clavi- 
cle. ^  It  is  also  possible,  that  the  enlargement  of  the  ends  of 
bones  of  rickety  persons  may  be  mistaken  for  exostosis;  but 
though  this  kind  of  enlargement  does  not  constitute  a  real  ex- 
ostosis, yet  it  cannot  be  denied  but  that  some  analogy  does  ex- 
ist between  them.  Another  species  of  tumour  which  might  be 
mistaken  for  an  exostosis,  is  that  formed  by  fungous  excrescen- 
ces growing  from  the  dura  mater,  which,  after  having  destroyed 
a  part  of  the  bones  of  the  cranium,  protrude  externally;  but 
the  real  nature  of  these  may  be  discovered  by  an  attentive  ex- 
amination of  their  consistence  and  progress,  and  by  attending 
to  the  pulsation  of  them,  which  is  evident  and  synchronous 
with  those  of  the  heart. 

The  efFe(Sts  of  exostosis  may  be  divided  into  general  and 
particular:  thus  the  swelling  is  accompanied  by  a  sense  of 
weight;  pain  is  produced  by  the  morbid  adtion,  and  the  affect- 
ed part  is  necessarily  deformed. 

Its  particular  effects  arise  from  its  situation:  thus,  should  an 
exostosis  take  place  in  the  orbit,  the  eye  would  necessarily  be 
expelled  from  that  cavity;  and  an  expulsion  of  the  eye  from 
that  cause  has  in  faft  been  observed.  Should  a  tumour  of  this 
nature  arise  from  the  clavicle  or  sternum  internally,  it  might 
occasion  death,  by  compressing  the  principal  blood  vessels,  ar- 
terial or  venous.  An  exostosis  of  the  pubis  might,  as  already 
mentioned,  occasion  a  retention  of  urine;  or  a  similar  tumour 
on  any  of  the  bones  of  the  pelvis,  internally,  might  render 
parturition  in  the  natural  way  impossible. 
'  The  prognosis  differs  according  to  the  nature  of  the  primary 
disease  from  which  t;ie  exostosis  originates,  and  according  to 
the  particular  change  in  the  texture  of  the  bone.     Exostoses 


OF    EXOSTOSIS.  179 

from  an  external  cause  are  much  more  difficult  to  cure  than 
those  arising  from  an  internal  one;  because  the  latter  may  be 
combated  by  appropriate  medicines;  but  in  the  former,  no  in- 
ternal remedy  can  have  any  effect,  and  the  extirpation  of  the 
tumour  is  the  only  expedient.  An  exostosis  produced  by  a  scro- 
fulous diathesis  is  much  more  difficult  to  cure  than  that  arising 
from  any  other  constitutional  disease.  Unfortunately,  medicines 
have  been  as  yet  found  ineffectual  in  scrofula,  and  the  pradli- 
tioner  has  generally  the  mortification  of  seeing  exostosis  from 
this  cause  mock  his  general  remedies,  and  pass  on  to  a  caries, 
to  which  it  has  a  particular  tendency. 

The  ivory  exostosis,  if  situated  so  as  not  to  impede  the  adlion 
of  any  organ,  is  the  least  dangerous  of  all ;  for  although  it  be 
impossible  to  procure  the  absorption  of  this  tumour,  in  which 
no  vessel,  nor  fibre,  nor  pore,  can  be  discovered,  and  which 
appears  a  compadl  and  homogeneous  mass,  yet  after  it  has 
gradually  acquired  a  certain  volume,  which  is  never  very  great, 
it  becomes  stationary,  and  causes  no  inconvenience,  but  that 
arising  from  Its  weight. 

Our  complete  ignorance  of  the  pathology  of  exostosis,  or  of 
the  manner  in  which  it  is  formed,  accounts  for  the  Imperfection 
of  our  treatment  of  It.  The  opinion  of  J.  L.  Petit,  relative  to 
it,  is  at  present  totally  abandoned:  that  author  attributed  the 
greater  part  of  the  diseases  of  the  bones  to  a  defect  of  elasticity 
in  the  periosteum.  We  find  nothing  more  probable  in  the 
opinion  of  a  more  modern  author,  who  attributes  exostosis  to  a 
diminution  of  the  natural  quantity  of  phosphoric  acid. 

We  shall  however  endeavour  to  lay  down  some  principles  for 
the  treatment  of  it.  The  first  step  to  be  taken.  Is  to  discover 
the  primary  disease,  which  when  once  ascertained,  must  be  the 
principal  object  of  treatment. 

If  the  patient  has  formerly  laboured  under  a  venereal  affec- 
tion, which  he  has  reason  to  think  has  not  been  totally  eradi- 
cated, or  if  there  are  venereal  symptoms  present,  the  exostosis 
may  be  safely  attributed  to  that  disease.  It  may  be  observed 
here,  that  a  venereal  taint  which  has  been  but  partially  com- 
bated, is  more  difficult  to  remove  than  that  for  which  no  remedy 
has  been  used.  At  all  events,  mercurial  preparations  are  to  be 
judiciously  administered,  and  the  use  of  them  persevered  in 
until  all  the  venereal  symptoms  disappear. 

This  mode  of  treatment  is  certainly  the  most  efficacious;  but 
should  the  evil  resist  the  use  of  the  milder  preparations  of  mer- 
cury, it  must  be  given  in  small  doses,  in  the  state  of  corrosive 


loo  OF    EXOSTOSIS. 

sublimate,  which  may  be  advantageously  dissolved  in  a  decoc- 
tion of  sarsaparilla,  or  other  sudorific  article.  If  mercury  in 
any  form  does  not  agree  with  the  patient,  sudorifics  alone  must 
be  used:  three  glasses  of  a  strong  decoction  of  sarsaparilla  and 
guaiacum,  in  which  a  few  grains  of  alcali  may  be  dissolved,  are 
to  be  given  daily;  and  the  tumour  is  to  be  covered  with  a 
mercurial  plaster.  If  the  pain  be  very  great,  and  prevent  sleep, 
some  opium  may  be  added  to  the  plaster.  This  latter  appli- 
cation som.etimes  aiTords  very  considerable  relief. 

When  the  anti-venereal  treatment  has  been  continued  for  two 
months  or  more,  if  the  venereal  symptoms  disappear,  and  the 
exostoses  diminish  in  size  and  become  indolent,  it  would  be 
useless  or  even  pernicious  to  persevere  in  the  use  of  the  general 
remedies.  It  is  not  unfrequcnt  to  find  nn  exostosis  which  was 
only  a  symptom  of  syphilis  continue  after  the  removal  of  the 
general  disease,  particularly  when  the  infection  has  existed  for 
a  length  of  time  in  the  system.  The  topical  affection  should 
in  this  case  be  left  to  nature,  if  its  situation  do  not  impede  the 
action  of  some  organ  essential  to  life;  under  which  circum- 
stances, its  removal  by  an  operation  becomes  necessary. 

In  treating  a  venereal  exostosis  by  mercurial  reinedies,  it  is 
of  tb£  utmost  importance  to  regulate  their  use  in  such  a  man- 
ner as  that  the  mouth  may  be  but  slightly  affedted,  and  a  sali- 
vation avoided.  Little  reliance  can  be  had  on  the  topical  ap- 
plications, with  which  the  tumour  is  generally  covered ;  nor  can 
it  be  reasonably  expected  that  they  should  adl  efFedlually  on  the 
osseous  system,  through  the  integuments  and  soft  parts.  Hem- 
lock plasters,  and  similar  applications,  only  irritate  the  skin,  and 
occasion  erysipelas  and  excoriations,  which  add  to  the  suffer- 
ings of  the  patient. 

The  sci'ofulous  exostosis  is  opposed  by  the  internal  use  of 
tonic  medicines,  by  the  application  of  discutients  to  the  part, 
by  sea-bathing,  or  by  pumping  on  the  part  water  in  which 
some  alcali  has  been  dissolved.  But  often  all  our  endeavours 
are  fruitless ;  the  exostosis  degenerates  into  caries ;  the  soft 
parts  which  cover  the  diseased  bone  become  inflamed,  and  ab- 
scesses are  formed,  the  openings  of  v'/hlch  become  fistulous. 
The  slow  fever  which  ensues  from  the  absorption  of  the  pus 
and  the  copious  discharge,  exhaust  the  patient's  strength,  and 
the  only  resource  that  now  remains  is  amputation;  but  this 
even  is  sometimes  impracticable,  from  the  situation  or  extent 
of  the  diseased  part. 


OF    EXOSTOSIS.  l8l 

When,  as  is  generally  the  case,  the  scrofulous  exostosis  ter- 
minates in  caries,  the  treatment  will  be  the  same  as  if  caries  had 
supervened  without  being  preceded  by  exostosis. 

The  scorbutic  exostosis  requires  the  same  treatment  as  the 
disease  of  which  it  is  a  symptom.  As  to  the  cancerous  exos- 
tosis, which  is  as  rare  as  the  scorbutic,  its  cure  is  as  difhcult  as 
that  of  cancer  itself.  When  the  part  cannot  be  extirpated, 
opiates  and  other  palliative  means  are  to  be  had  recourse  to. 

If  the  disease  has  originated  from  an  external  cause,  or  if  it 
be  merely  local,  the  primary  disease  of  which  it  was  a  symptom 
being  removed,  it  is  best  to  leave  it  to  nature.  The  use  of 
caustics,  or  the  actual  cautery,  occasions  much  pain,  and,  in- 
stead of  doing  good,  adds  to  the  evil.  This  is  the  case  with 
an  unfortunate  woman,  who  had  caustic  applied  to  an  exostosis 
of  the  internal  side  of  the  tibia-,  but  which,  instead  of  remo- 
ving the  exostosis,  produced  a  necrosis,  of  which  she  is  not 
yet  well,  though  two  years  have  elapsed  since  the  application 
of  the  caustic.  How  ever,  should  the  tumour,  from  its  situa- 
tion or  size,  press  on,  and  derange  some  important  organ,  as 
the  eye  for  instance,  which  it  may  turn  to  one  side  or  the 
other,  or  totally  expel  from  the  orbit,  it  will  be  necessary  to 
proceed  to  the  follov.'ing  operation. 

If  the  tumour  rise  from  one  of  the  broad  bones  of  the  skull, 
to  which  it  is  connedled  by  a  narrow  neck,  the  integuments 
over  it  are  divided  by  a  crucial  incision,  and  dissefled  from  the 
bone.  The  periosteum  is  then  to  be  cut  round  the  neck  of  the 
tumour,  which  is  finally  removed  by  a  thin  sharp  saw.  This 
mode  of  operating  is  much  to  be  preferred,  even  when  the 
neck  of  the  tumour  is  not  very  narrow,  to  that  in  which  a 
chisel,  and  mallet  of  lead,  are  used;  for  the  concussion  given 
to  the  brain  by  the  latter  mode  may  bring  about  the  worst 
consequences.  If  the  base  of  the  tumour  be  so  thick,  that  it 
cannot  be  sawed  through  by  a  small  fine  saw,  it  will  be  neces- 
sary to  divide  it  into  several  parts  by  vertical  sections,  which 
parts  may  be  easily  sawed  through  in  succession. 

When  the  chisel  and  mallet  are  used,  it  will  be  necessary  to 
fix  immovably  the  part  to  be  acted  on,  and  to  direct  the  chisel 
obliquely,  so  that  its  aftion  by  cutting  maybe  increased.  If 
after  having  removed  in  this  manner  the  greater  part  of  the 
tumour,  its  base  be  found  carious,  it  will  be  necessary  to  re- 
move by  the  chisel,  or  even  a  scraper,  as  much  as  possible  of 
the  diseased  part,  and  to  destroy  what  remains  by  the  atSlual 
cautery. 


l82  OF    OSTEO-SARCOMA. 

If  the  tumour  to  be  removed  by  the  chisel  be  very  thick,  it 
will  be  necessary  to  make  holes  in  it  in  different  points  by  a 
perfornniLj  instrument,  by  which  means  its  basis  will  be  dimi- 
nished, and  its  removal  facilitated.  After  the  tumour  has 
been  removed,  granulations  sprout  from  the  surface  of  the 
bone,  and  in  a  little  time  the  wound  is  cicatrized.  But  I  must 
remark,  that  cases  rarely  occur,  in  which  it  would  be  justifia- 
ble to  perform  this  operation,  and  that  in  by  far  the  greater 
number  of  instances  the  local  affection  is  much  less  to  be 
dreaded  than  the  means  used  for  removing  it. 

We  have  designedly  omitted  mentioning  the  lamellated  ex- 
ostosis, in  which  the  internal  part  of  the  diseased  bone  is  con- 
verted into  flesh.  This  species  of  disease  has  been  improperly 
confounded  with  exostosis,  but  it  more  properly  belongs  to 
those  classed  under  the  general  name  of  osteo-sarcoma. 


CHAPTER  XXII. 


OF  OSTEO-SARCOMA. 

WE  comprehend  under  this  denomination  all  the  osseous 
tumours  to  which  authors  have  given  the  different 
names  of  spina  ventosa,  poedarthroeace,  and  osteo-sarcoma ; 
but  in  colledling  them  thus  under  one  general  name,  we  do  not 
mean  to  say  that  these  different  denominations  refer  to  a  single 
disease,  but  merely  that  they  have,  notwithstanding  their  dif- 
ferences, certain  points  of  resemblance  which  justify  this  clas- 
sification. It  is  extremely  difficult,  says  Marcus  Aurelius 
Severin,  to  ascertain  to  what  kind  of  organic  lesion  this  affec- 
tion is  to  be  ascribed.*  The  bone  affedled  is  sometimes  totally 
converted  into  a  soft,  lardy,  homogeneous  substance,  resem- 

*  Non  est  sane  facile  decerni  quo  sit  genere  ccnsendus  hie  affeflus.  Mar. 
Aur.  Sev.  de  Poedarthroeace. 


OF    OSTEO-SARCOMA.  183 

bling  a  concerous  gland.  At  other  times  it  is  filled  with  fun- 
gous flesh,  which  is  covered  exteriorly  by  a  thin  plate  of  com- 
padl  substance,  perforated  by  a  great  number  of  holes;  finally, 
there  are  cases  in  which  the  bone  becomes  reduced  into  a  soft 
gelatinous  substance.  We  shall  give  a  remarkable  example  of 
this  species  at  the  end  of  this  chapter. 

The  first  species  or  variety  which  we  have  mentioned  is  that 
which  merits  particularly  the  name  of  osteo-sarcoma,  which 
signifies,  in  itself,  the  conversion  of  an  osseous  substance  into 
flesh:  it  may  be  doubted,  however,  if  the  name  of  flesh  be 
properly  applied  to  this  substance,  which  resembles  rather  a 
scirrhus  of  soft  parts  than  flesh,  and  which  presents  no  mark 
of  organization.  The  soft  parts  which  surround  a  bone  thus 
afl'ected  participate  in  the  disease,  which  is  always  announced 
by  very  acute  pains,  and  which  originates  sometimes  from  an 
internal  disease,  and  particularly  from  the  cancerous  virus;  at 
other  times,  from  an  external  cause,  as  a  violent  contusion:  in 
many  cases  it  can  be  traced  to  no  cause. 

The  second  species,  named  spina  ventosa,  or  pcedarthrocace, 
consists  in  a  swelHng  of  the  head  or  body  of  a  long  bone,  in 
such  a  manner  as  that  its  cancelli  become  very  much  enlarged. 
The  medullary  membrane  which  lines  these  cancelli  becomes 
thick,  and  granulations  sprout  from  it,  which  destroy  by  their 
growth  the  substance  of  the  bone,  so  that  there  only  remains 
an  external  shell  filled  with  small  holes.  To  this  species  must 
be  referred  the  swellings  of  the  articulations  of  the  phalanges, 
arising  from  scrofula,  and  which  often  lead  to  the  necessity  of 
amputating.  This  operation  should  not,  however,  be  hastily 
recurred  to,  as  nature  sometimes  effe£ls  a  cure  in  which  she 
may  be  aided  by  bathing  the  parts  in  a  diluted  solution  of  pot- 
ash or  soap- water.  When  a  bone  that  has  been  thus  diseased 
is  macerated,  the  internal  fleshy  substance  separates,  and  the 
dilated  bone  remains  a  mere  empty  and  brittle  shell. 

In  every  species  of  this  disease,  the  pains  are  at  first  dull 
and  deep-seated,  but  in  a  short  time  they  become  more  in- 
tense, and  the  volume  of  the  bone  increases,  though  the  soft 
parts  appear  yet  in  their  natural  state.  The  latter,  however, 
soon  become  red  and  inflamed,  and  abscesses  form  in  them, 
which  burst,  and  their  openings  degenerate  into  fistulx. 

The  osteo-sarcoma,  of  whatever  species,  is  in  general  a  dan- 
gerous disease,  and  often  requires  the  amputation  of  the  part 
afFedted.  When  a  tendency  to  this  disease  from  a  venereal 
cause  is  discovered  early,  its  progress  may  be  prevented;  but 


184  OF    OGTEO-SARCOMA. 

if  the  disorganization  of  the  bone  has  once  taken  place,  its 
structure  can  never  be  restored.  The  swellings  of  the  extre- 
mities of  the  phalanges  of  the  fingers  and  toes  are  the  least 
alarming  of  all  affections  of  this  kind.  They  seldom  render 
amputation  necessary;  in  general,  the  wound  in  the  integu- 
ments puts  on  a  more  healthy  appearance,  the  fistulse  dry  up 
and  heal,  and  the  patient  recovers,  but  with  the  loss  it  is  true, 
of , the  motion  of  the  joint. 

When  the  structure  of  3  large  portion  of  bone  is  disorgan- 
ized by  osteo-sareoma  or  spina  ventosa,  and  the  patient  har- 
rassed  by  acute  pain,  and  exhausted  by  slow  fever,  diarrhoea, 
and  colliquative  sweats,  it  will  be  necessary  to  amputate  the 
part,  if  the  operation  be  practicable.  But  should  the  extent 
or  situation  of  the  evil  render  amputation  useless  or  impracti- 
cable, all  that  can  then  be  done  is  to  support  the  patient's 
strength  by  an  invigorating  diet  and  tonic  medicines,  and  pal- 
liate his  sufferings  by  means  of  opium. 

Amputation  is  generally  successful,  except  in  cases  of  real 
osteo-sarcoma,  which,  absolutely  analogous  to  a  carcinomatous 
affection  of  the  soft  parts,  takes  deep  root,  and  may,  like  it, 
attack  the  bone  again  after  this  operation  has  been  performed. 
This  return  is  particularly  to  be  apprehended  when  the  lym- 
phatic glands  in  the  neighbourhood  of  the  diseased  part  are 
swelled  and  indurated. 

We  have  spoken  of  a  particular  disorganization  of  the  bones, 
in  which  their  substance,  and  that  of  the  surrounding  soft 
parts,  become  soft,  and  are  converted  into  a  gelatinous  mass. 
The  following  case  presents  a  remai-kable  instance  of  this  spe- 
cies of  osteo-sarcoma. 

A  priest,  aged  forty-seven,  fell  as  he  was  running  in  the  Rue 
de  Barres,  the  1 3th  Vendemaire,  year  7,  and  received  a  con- 
tusion on  the  right  shoulder,  v/hich  was  not,  however,  so  con- 
siderable as  to  prevent  him  from  attending  to  his  usual  occu- 
pations; both  pain  ind  contusion  vanislied  in  a  short  time. 
Four  months  after  he  felt  intermittent  pains  in  the  right  arm, 
which  were  relieved  by  extending  the  arm  forcibly.  A  tu- 
mour as  large  as  an  egg  manifested  itself  near  the  shoulder,  the 
pain  arising  from  which  was  assuaged  by  volatile  liniment ;  but 
it  soon  became  very  acute,  and  the  arm  lost  the  power  of  mo- 
tion. He  was  received  in  this  state  into  the  Hotel-Dieu,  where 
he  remained  two  months,  during  which  time  the  shoulder  was 
kept  covered  with  emollient  poultices.  The  pain  diminished, 
but  the  tumour,  which  had  been  stationary,  increased  rapidly 


OF    OSTEO-SARCOMA.  1 85 

in  size,  and  extended  over  the  shoulder  and  into  the  armpit. 
After  leaving  the  Hotel  Dieu,  he  remained  with  his  friends 
until  the  2d  Ventose,  year  9,  when  he  entered  the  hospital  of 
St.  Louis.  The  tumour,  or  rather  the  shoulder  (for  that  part, 
though  much  increased  in  size,  had  not  lost  its  natural  shape), 
was  moveable,  though  it  appeared  to  be  connedled  by  some 
points  to  the  side  of  the  thorax:  it  was  equally  hard  and  elastic 
in  every  part,  but  little  eminences  were  formed  on  its  surface. 
The  skin,  though  very  much  distended,  had  preserved  its  na- 
tural colour,  and  a  considerable  degree  of  pressure  might  be 
made  on  the  tumour  without  increasing  the  pain.  The  right 
trapezius  muscle,  which  supported  principally  the  weight  of  the 
tumour,  was  much  extended,  and  drawn  into  the  shape  of  a 
cord  visible  through  the  skin.  The  pain  appeared  to  be  pro- 
duced by  the  extension  of  the  skin  and  compression  of  the  aux- 
iliary plexus  of  nerves:  its  violence  was  considerably  diminished 
by  emollient  applications  and  by  the  use  of  opiates,  the  dose  of 
which  it  was  found  necessary  to  augment  when  the  atmosphere 
seemed  overcharged  with  elesflricity ;  as  the  pain  was  then  much 
increased,  and  seemed  to  dart  in  different  directions  tlirough 
the  tumour  with  the  rapidity  of  lightning.  The  great  extent 
of  the  swelling  of  the  lateral  and  superior  parts  of  the  thorax, 
our  ignorance  of  its  nature,  and  of  the  real  state  of  the  articula- 
tion, prevented  us  from  amputating  at  the  shoulder  joint. 

The  tumour  continued  to  augment,  and  the  pains  to  become 
more  intense;  the  emaciation  and  debility  increased;  opium 
could  no  more  procure  sleep  or  diminish  pain;  diarrhcEa  came 
on,  and  the  patient  died  on  the  2d  Fru6lidor,  five  months  after 
his  entrance  into  the  hospital  of  St.  Louis.  The  tension  of  the 
skin  of  the  tumour  seemed  to  diminish,  and  the  tumour  itself 
to  collapse,  on  the  moment  of  the  patient's  death.  Its  circum- 
ference was  still  thirty-six  inches,  and  its  diameter  sixteen:  its 
weight,  with  that  of  the  arm,  was  about  thirty-three  pounds, 
while  that  of  the  other  arm  was  only  about  six,  which  left  a 
difference  of  twenty-nine  pounds.  When  the  skin  was  thus 
relaxed,  a  fluftuation  was  perceptible,  which  could  not  be  felt 
before,  unless  in  the  little  eminences  on  the  surface,  which 
were  liable  to  disappear  and  change  their  situation.  A  trocar 
was  twice  plunged  into  the  tumour  in  different  parts,  yet  no 
fluid  escaped.  I  then  opened  it  in  presence  of  Citizen  Lassus, 
Thouret,  and  many  other  practitioners. 

The  skin  was  thinner  than  natural,  and  its  texture  decom- 
posed :  that  is,  the  fibres  and  lamellae  of  which  it  is  composed 
24. 


l86  OF    OSTEO-SARCOMA. 

were  separated  and  distin£l.  The  muscles,  and  particularly  the 
deltoides,  were  extremely  emaciated,  and  seemed  to  form  a 
second  fleshy  covering  not  more  than  one  line  thick.  A  yellow 
gelatinous  mass  was  found  in  the  centre,  and  which  resembled, 
in  many  respe^ls,  jelly  in  which  some  blood  had  been  mixed. 
The  humerus  was  nearly  destroyed  to  its  inferior  extremity. 
The  nerves  and  arteries,  pressed  against  the  integuments,  did 
not  seem  to  have  been  injured.  The  surface  of  the  glenoid 
cavity  was  destroyed,  and  converted  into  a  gelatinous  substance. 
A  chemical  analysis  of  this  substance  proved  it  to  be  composed 
of  a  great  proportion  of  gluten,  a  small  quantity  of  albumen, 
and  some  salts.  The  clavicle  was  found  in  a  healthy  state,  and 
no  part  of  the  scapula  was  affected  but  that  which  forms  the 
glenoid  cavity. 

The  diseased  part  has  been  preserved,  and  deposited  in  the 
Anatomical  Gallery  of  the  School  of  Medicine  of  Paris;  where 
also  may  be  seen  a  drawing  of  the  tumour  in  the  last  stages  of 
the  disease.  An  idea  of  it  may  be  formed  from  an  attentive  ex- 
amination of  a  drawing  given  by  Marc.  Aur.  Severin*  of  a 
Spaniard  who  died  of  a  similar  tumour. 

There  are  other  examples  of  similar  tumours.  Citizen  Las- 
sus  has  colledled  the  particulars  of  a  great  number  of  cases  of 
this  kind,  and  has  made  them  the  subject  of  an  Essay  presented 
to  the  School  of  Medicine. 


*  De  recondita  Abscessinm  Natura,  edit,  de  Leyd. 


VOLUME  II, 


A  TREATISE, 


CHAPTER  1. 


OF  RICKETS. 


THIS  disease  Is  most  generally  met  with  in  young  chil- 
dren, and  but  very  seldom  in  adults;  however,  persons 
that  have  suffered  from  it  in  their  youth,  may  be  attacked  with 
it  after  puberty.  The  memorable  case  given  by  Morand  in  the 
Memoirs  of  the  Academy  of  Sciences,  1753,  furnishes  a  re- 
markable instance  of  its  attack  after  this  period  of  life. 

The  bones  of  the  foetus  whilst  in  the  womb  may  be  affedled 
by  it:  Pinel  has  given,  in  Fourcroy's  Journal,  a  description  of 
the  skeleton  of  a  ricketty  foetus.  But  it  most  generally  mani- 
fests itself  from  the  sixth  or  seventh  month,  to  the  fourteenth 
or  fifteenth,  or  much  about  the  period  of  the  first  dentition. 
J.  L.  Petit,  and  many  others,  have  considered  difiicult  cutting 
of  the  teeth  as  a  principal  cause  of  it. 

It  is  not  as  yet  decided  whether  this  disease,  the  charafteris- 
tic  mark  of  which  is  a  softening  of  the  bones  from  a  deficiency 
of  phosphate  of  lime,  be  a  primary  affe£lion,  or  a  symptom  of 
scrofula,  lues,  or  scurvy:  Do<fl:or  Portal  maintains  the  latter 
opinion. 


190  OF    RICKETS. 

"We  will  observe,  however,  that  there  seems  to  be  a  great 
connexion  between  rickets  and  scrofula:  the  swelling  of  the 
mesenteric  glands,  the  colour  of  the  skin,  the  flaccidity  of  the 
muscles,  and  other  symptoms  observed  in  rickets,  are  marks 
of  a  scrofulous  diathesis. 

Whatever  may  be  its  cause,  its  progress  is  as  follows:  the 
child  generally  suffers  from  cutting  his  teeth,  and  is  tormented 
for  some  time  by  a  continual  diarrhoea;  at  length  the  belly 
swells,  and  becomes  hard  and  tense;  the  skin  is  now  dry  and 
scaly:  the  limbs  diminish  in  thickness,  and  the  whole  body 
becomes  emaciated;  the  ends  of  the  bones  swell,  and  the  joints 
of  the  extremities  appear  like  so  many  knots;  the  bones  lose 
their  consistence,  or  become  flexible,  and  the  muscular  sub- 
stance decays.  The  patient,  reduced  to  this  miserable  state,  is 
incapable  of  moving,  and  every  effort  he  makes,  or  even  the 
weight  of  his  body,  bends  the  bones.  The  head  preserves, 
however,  its  natural  size,  and  in  most  cases  becomes  even 
larger  than  natural.  The  brain,  which  does  not  seem  to  share 
in  the  general  dissolution,  becomes  evolved,  its  extension  not 
being  opposed  by  the  softened  bones  in  which  it  is  included, 
and  the  understanding  is  prematurely  developed.  The  eyes 
have  an  uncommon  brilliancy,  and  all  the  senses  are  extremely 
acute:  however,  cases  have  been  met  In  which  great  marks  of 
stupidity  or  dulness  accompanied  the  disease. 

The  affection  does  not  always  stop  here;  sometimes  the 
bones  become  carious,  or  a  white  svv^eliing  appears  in  some  of 
the  joints;  either  of  which  in  general  proves  fatal. 

The  vertebral  column  is  particularly  liable  to  be  affefted  by 
rickets,  and  the  disease  is  sometimes  confined  to  it  alone. 
When  the  cervical  vertebrx  are  attacked,  the  anterior  part  of 
the  neck  projects,  and  the  head  falls  backwards,  and  appears 
sunk  between  the  shoulders.  When  the  affedlion  is  general, 
the  vertebral  column  becomes  shorter,  and  is  curved  in  various 
directions;  the  breast  beomes  deformed,  not  only  in  conse- 
quence of  the  curvature  of  the  spine,  but  by  the  depression  of' 
the  ribs  and  projection  of  the  sternum;  the  bones  of  the  pelvis 
fall  inwards,'  and  generally  the  pubis  approaches,  the  sacrum; 
and  the  diameters  of  the  pelvis  are  so  much  diminished,  that, 
parturition  must  be  rendered  difficult  or  impossible.  Howe- 
ver, some  women  deformed  by  rickets,  bring  forth  full-grown 
children,  without  any  difficulty;  but  I  believe  that  in  such 
cases  the  rickets  come  on  after  puberty,  at  which  time  there  is 
much  less  danger  of  the  pelvis  being  aftedted  than  in  infancy. 


OF    RICKETS.  191 

The  curvature  of  the  clavicles  increases,  and  becomes  more 
prominent  anteriorly;  the  scapulae  grow  shorter;  the  humeri 
become  curved  outward  towards  their  superior  part,  wliilst 
their  inferior  is  carried  forwards;  the  bones  of  the  fore-arms 
are  curved  in  the  same  manner;  but  the  superior  extremities, 
as  they  do  not  support  any  part  of  the  weight  of  the  body,  are 
always  much  less  deformed  than  the  inferior,  and  they  are 
always  bent  towards  that  side  into. which  the  most  powerful 
muscles  are  inserted. 

The  bones  of  the  thighs  are  curved  forwards  or  outwards,  the 
anterior  and  external  parts  of  the  thigh  becoming  more  promi- 
nent; the  neck  of  the  femur,  from  being  oblique,  becomes 
perpendicular  with  the  body  of  the  bone;  the  knees  fall  in- 
wards; the  internal  and  anterior  sides  of  the  tibia  become  con- 
vex, and  the  external  side  of  the  legs  concave;  the  feet  are 
thrown  outwards,  not  only  on  account  of  the  knees  falling  in, 
but  also,  because  the  inferior  end  of  the  fibula  cannot  suffici- 
ently oppose  the  abduction  of  the  foot. 

Nothing  certain  has  been  ascertained  as  to  the  proximate 
cause  of  rickets;  conjedlures  however  have  not  been  wanting 
on  this  subject.  Some  have  supposed  that  the  bones  are  de- 
prived of  their  phosphate  by  an  acid;  but  what  acid  is  this? 
How  is  it  generated  ?  Does  the  acid  smell  of  the  breath  of  the 
ricketty  patient  indicate  any  thing  respecting  it,'' 

Is  the  softening  of  the  bones  owing  to  a  defeat  of  reparation, 
while  their  ordinary  loss  is  going  on?  or  is  there  a  disease  in 
the  bones  by  which  they  are  decomposed  and  consumed,  whilst 
the  digestive  organs  do  not  furnish  a  sufficient  supply  of  calca- 
rious  phosphate  ?  or  is  the  passage  of  this  salt  from  the  chylo- 
poetic  viscera  prevented  by  the  obstruftion  of  the  mesenteric 
glands?  We  must  acknowledge  that  ricketty  patients,  notwith- 
standing their  voracious  appetite,  appear  to  digest  their  food 
but  badly,  and  that  the  passage  of  the  chyle  must  be  impeded 
by  the  obstruftion  of  the  mesenteric  glands,  in  which  calcareous 
concretions  have  been  found;  lastly,  does  the  chyle  contain  a 
less  quantity  of  phosphate  of  lime  than  natural?  or  does  this 
salt,  instead  of  being  deposited  in  the  bones,  pass  to  other 
parts?  and  what  is  the  cause  of  this  deviation? 

If  the  body  be  anatomically  inspected  after  death,  the  parts 
will  be  found  in  the  following  state: 

The  muscles  are  pale  and  emaciated;  the  cellular  substance 
is  quite  destitute  of  fat;  the  brain  is  in  general  found  larger 
than  natural,  soft,  and  containing  a  preternatural  portion  of 


192  OF    RICKETS. 

humidity;  the  spleen  and  liver  are  flaccid  and  enlarged;  the 
intestines  are  pale,  or  rather  whitish;  all  the  lymphatic  glands, 
especially  those  of  the  mesentery  and  bronchiac,  are  enlarged, 
and  the  latter  sometimes  suppurated;  the  bones,  reduced  to 
their  fibrous  state,  are  flexible,  bent  in  several  diredtions,  and 
easily  cut. 

There  have  been  various  opinions  as  to  the  cause  of  the  cur- 
vature of  the  bones.  Glisson,  who  wrote  towards  the  middle 
of  the  seventeenth  century,  is  the  first  who  expressly  treated 
of  rickets:  his  explanation  of  the  curvature  is  as  follows: 

The  humours,  says  he,  that  go  to  nourish  the  bones,  are 
accumulated  more  on  one  side  than  on  the  other,  and  thus  curve 
the  bone,  or  make  it  incline  to  the  opposite  side,  in  the  same 
manner  as  a  column  might  be  curved  by  introducing  in  the 
same  line,  and  on  the  same  side,  wedges  between  its  different 
parts.  But  how  is  it  proved  that  the  humours  are  deposited 
on  one  side  in  preference  to  another?  and  how  comes  it  that 
the  curvature  takes  place  in  most  persons  in  the  same  direc- 
tion ? 

Mayow,  an  English  author,  gives  the  following  hypothesis: 
the  tendons  being  dry  and  shortened,  oppose  the  elongation 
of  the  bones,  and  bend  them  in  the  same  way  as  a  young  tree 
is  bent,  by  bringing  both  its  ends  towards  one  another  by 
means  of  a  cord.  But,  without  having  recourse  to  this  far- 
fetched comparison,  we  find  an  easy  and  natural  explanation 
of  the  fadl  in  the  effects  of  the  weight  of  the  body,  and  mus- 
cular contradlion.  The  deviations  are  in  general  an  excess  of 
the  natural  curvature;  and  it  is  easy  to  conceive  that  the  weight 
of  the  body,  and  muscular  a6lion,  which  produce  this  natural 
curvature,  may  occasion  an  excess  of  it,  when  the  bones  are 
incapable  of  resisting  the  forces  that  adl  on  them.  It  is  also 
found  that  the  natural  as  well  as  the  diseased  curvature  is  al- 
ways in  the  diredlion  in  which  the  most  powerful  muscles  a6l; 
thus  the  tibia  and  fibula  are  curved  outwards  and  backwards; 
and  the  femur  is  curved  inwards  and  backwards,  the  muscles 
of  the  internal  and  posterior  part  of  the  thigh  being  more 
powerful  than  those  of  the  external  and  anterior. 

Rickets  is  an  hereditary  disease  in  some  families,  though 
parents  that  have  been  affected  with  it,  have  sometimes  a 
healthy  and  robust  offspring.  I  think  it  can  be  traced,  in 
some  instances,  to  a  venereal  taint,  which,  though  not  the 
immediate  cause,  is  very  often  an  exciting  cause  of  it  and  scro- 
fula.    At  least,  it  is  certain  that  syphilis  transmitted  from  pa- 


OF    RICKETS.  193 

rents  to  their  children,  appears  in  the  latter  in  a  manner  very 
different  from  that  in  which  the  former  are  affefted.  Thus 
we  find,  that  the  children  of  the  indigent  and  profligate  are 
those  most  generally  affected  with  rickets;  but  at  the  same 
time  it  must  be  allowed,  that  there  are  many  circumstances 
which  conduce  to  this  disease;  such  as  a  damp  and  cold  resi- 
dence, impure  air,  inattention  to  cleanliness,  and  a  deficiency 
of  food. 

Though,  we  do  not  fully  adopt  the  opinion  of  Petit  as  to  the 
influence  of  dentition,  still  we  must  allow  that  the  aftion  then 
going  on  in  the  osseous  system,  must  be  intimately  connected 
with  the  cutting  of  the  teeth;  and  that  difficult  dentition,  tlue 
pain  and  bowel  complaints  arising  from  it,  may  favour,  in  a 
powerful  manner,  the  action  of  the  exciting  causes  of  rickets. 

It  is  singular  enough  that  the  teeth  preserve  their  hardness, 
though  they  become  loose  from  the  softening  of  the  alveolar 
processes:  the  softening  of  the  jaw  bones  is  sometimes  attended 
with  excessive  pain,  but  at  other  times  it  takes  place  without 
any  pain  at  all. 

The  prognosis  is  always  unfavourable  in  rickets;  there  is  no 
medicine  which  afts  directly  against  it :  and  even  in  the  most 
favourable  cases  it  is  impossible  to  guard  against  deformity. 
However,  the  danger  to  life  is  great  in  proportion  to  the  num- 
ber of  bones  affedled,  the  more  or  less  speedy  progress  of  the 
disease,  and  the  age  of  the  patient.  Children  at  the  breast  are 
in  greater  danger  than  those  that  have  rieached  three  or  four 
years.  If  the  bones  about  the  thorax  be  considerably  affected, 
the  cavity  is  diminished,  the  lungs  are  compressed,  the  func- 
tion of  respiration  goes  on  imperfectly,  and  hence  a  number  of 
diseases  which  are  fatal  of  themselves. 

Sometimes  the  disease  advances  but  slowly,  and  the  patient 
arrives  at  puberty  before  he  is  quite  well;  but  the  great  revo- 
lution that  takes  place  in  his  system  at  this  time,  arrests  the 
progress  of  the  complaint.  Measles,  small-pox,  and  other 
diseases  to  which  children  are  subjeft,  have  sometimes  brought 
about  this  happy  termination:  the  limbs  recovered  their  size, 
the  enlargement  of  the  joints  disappeared,  and  no  mark  of 
rickets  remained  but  the  deformity. 

We  know  of  no  medicine  which  can  be  said  to  possess  any 
efiicacy  in  this  disease :  tonics  are  indicated,  and  they  should 
be  used.  But  the  principal  advantage  is  to  be  derived  from 
general  treatment:  the  patient,  if  resident  in  a  city,  is  to  be 
removed  to  the  country,  where  an  elevated  and  dry  situation 


194  <5F    RICKETS. 

should  be  chosen;  he  is  to  be  supplied  with  a  nourishing  diet, 
and  a  moderate  quantity  of  wine.  But  as  the  poor,  amonsj 
whom  the  disease  is  most  frequently  observed,  cannot  change 
their  residence,  they  should  be  placed  in  the  highest  apartment 
of  the  house,  which  should  be  kept  well  ventilated;  and  in  the 
warm  season  the  patient  covered  with  a  shirt,  should  be  exposed 
for  a  considerable  time  every  day  to  the  sun;  care,  however, 
should  be  taken  that  his  head  be  protected  against  the  influence 
of  the  rays. 

The  bed  on  which  ricketty  patients  lie,  should  consist  of  no- 
thing more  than  a  hair  mattress,  or  oaten  chaff;  or  it  might 
be  made  of  dried  fern-leaves,  among  which  some  aromatic 
herbs  were  mixed.  Such  beds  are  much  better  than  those 
made  of  feathers;  for  they  do  not  yield  to  the  weight  of  the 
body,  and  they  are  much  drier.  If  the  patient  be  very  young, 
he  should  be  placed  on  his  back,  so  that  the  weight  of  his 
body  may  have  as  little  influence  as  possible  on  the  bones;  but 
as  it  is  painful  to  remain  constantly  in  this  position,  he  may  be 
allowed  to  sit  up  now  and  then,  but  not  on  a  soft  chair:  he  is 
to  be  placed  on  a  seat  capable  of  making  a  uniform  resistance, 
%vith  a  high  straight  back,  and  without  arms.  If  the  seat  were 
soft,  the  patient,  to  find  7i  point  d'appui,  would  incline  forwards; 
and  if  it  had  arms,  were  he  to  lean  on  them,  his  shoulders 
would  be  raised,  and  the  cervical  vertebra;  curved  forwards. 
He  should  not  be  allowed  to  walk  for  a  considerable  time;  for 
at  first  he  will  be  incapable  of  doing  so  without  assistance,  and 
the  strings  and  ribbands  necessary  for  supporting  him,  contri- 
bute, by  pressing  on  the  parietes  of  the  thorax,  to  deform  that 
cavity. 

EriiStions  are  useful.  They  may  be  made  either  with  dry 
flannel,  impregnated  with  aromatic  vapours,  or  with  flannel  wet 
with  mint,  rosemary,  lavender,  or  other  aromatic  waters.  A 
hair  brush,  much  used  by  the  English,  is  an  excellent  instru- 
ment for  this  purpose.  Frictions  determine  the  fluids  to  the 
surface  of  the  body,"  promote  perspiration,  and  increase  the 
circulation. 

The  clothing  should  be  wide,  and  composed  of  materials 
which  are  light,  and  which  do  not  transmit  freely  the  heat  of 
the  body.  If  the  patient  be  a  child  at  the  breast,  the  nurse's 
qualities  should  be  inquired  into;  if  she  is  feeble,  unhealthy)^ 
or  pregnant, .  the  child  should  be  committed  to  another  nurse, 
possessing  the  very  opposite  qualities.  If  the  child  be  --^'caned, 
he  is  to  be  nourished  with  well-fermented  bread,  and  animal 


OF    RICKETS.  195 

food  simply  roasted;  and  wine  is  to  be  allowed  him  in  small 
quantities,  often  repeated.  As  to  exercise,  if  it  do  not  in- 
crease the  curvature  of  the  bones,  as  much  of  it  should  be  taken 
as  will  not  fatigue  the  patient;  and  when  the  softness  of  the 
bones  is  such  that  any  exercise  which  would  require  conside- 
rable muscular  a6lion  cannot  be  used,  riding  in  a  carriage, 
or  sailing,  should  be  had  recourse  to. 

Independently  of  the  general  means  just  pointed  out,  there 
are  particular  remedies  which  may  be  used  in  cases  to  which 
they  are  adapted. 

If  the  patient  suffer  from  dentition,  that  is,  if  he  be  tor- 
mented with  griping  pains  and  diarrhoea,  or  if  he  shriek  se- 
verely now  and  then,  and  have  convulsive  twitches,  opium 
should  be  given.  If  he  be  troubled  with  worms,  rhubarb  and 
other  supposed  vermifuge  medicines  may  be  administered. 

It  is  very  common  to  find  ricketty  patients  troubled  with 
worms:  the  weakness  of  the  alimentary  canal,  and  the  quan- 
tity of  mucus  collected  in  it,  favour  the  generation  of  worms, 
the  existence  of  which  in  the  intestines  is  indicated  by  colic 
pains,  itching  of  the  nose,  acidity  of  the  breath  and  perspira- 
tion, dilation  of  the  pupil,  &c.  &c. 

We  may  endeavour  to  discuss  the  swelling  of  the  mesenteric 
glands,  by  small  doses  of  infusion  of  rhubarb,  and  by  repeated 
friftions  on  the  abdomen.  I  am  conjfident  that  much  benefit 
might  be  derived  in  these  cases  from  making  the  patient  laugh 
heartily  every  day,  by  tickling  him;  in  this  convulsive  motion, 
the  organs  contained  in  the  cavities  of  the  thorax  and  abdomen 
are  agitated  and  pressed  in  every  dire(5lion,  and  the  motion  of 
the  fluids  in  their  small  vessels  is  accelerated. 

If  it  appear  that  syphilis  or  scrofula  has  had  any  share  in 
producing  the  rickets,  the  treatment  applicable  to  each  of  these 
diseases  should  be  had  recourse  to.  In  case  of  a  venereal  taint 
being  the  cause,  tonics  should  be  combined  with  the  use  of 
mercurials;  for  the  latter,  by  itnducing  debility,  accelerate  the 
progress,  of  th?  rickets. 

The  knowledge  of  the  cause  of  the  softening  of  the  bones, 
necessarily  leads  to  endeavours  to  obviate  it,  or  repair  the  in- 
juries it  occasions.  But  how  are  we  to  introduce  a  sufliciency 
of  phosphate  of  hme.^  How  are  we  to  stimulate  the  absorbents, 
and  make  them  take  up  a  greater  portion  of  this  salt  ?  And, 
supposing  that  this  could  be  effected,  how  can  we  cause  it  to  be 
deposited  in  the  bones?  Madder,  from  its  known  property  of 
tinging  the  bones  red,  was  supposed  to  have  a  particular  action 


196  OF    RICKETS. 

on  the  osseous  system,  but  it  is  now  well  ascertained  that  It 
has  no  greater  effeft  in  rickets  than  any  other  bitter  plant. 

Thus  it  appears  that  our  chief  objedt  in  treating  this  disease, 
is  to  restore  general  health  and  strength  as  much  as  in  our 
power:  the  general  treatment  already  pointed  out,  is  what  is 
most  to  be  depended  on  for  this  purpose,  but  it  maybe  assisted 
by  the  use  of  bark  and  other  tonic  medicines. 

Mechanical  means  have  been  proposed  for  obviating  the  ef- 
fects of  this  disease.  It  is  nearly  useless  to  attempt  using  any 
machines  with  very  young  children,  and  it  is  also  impossible 
to  confine  them  on  their  back  in  bed;  besides,  it  would  be 
extremely  injurious  to  keep  them  confined  in  this  posture:  the 
continued  extension  of  the  limbs,  and  the  inadlivity  of  the 
muscles,  would  add  to  the  general  debility,  and  consequently 
increase  the  disease.  Splints,  then,  applied  to  the  limbs,  strong 
leather  boots,  and  the  apparatus  for  the  spine,  are  really  useful 
only  in  cases  in.which  the  patient  is  of  a  certain  age,  and  when 
the  progress  of  the  disease  is  gradual,  and  the  strengtfi  not  too 
much  exhausted;  and  even  in  most  of  these  cases,  the  inac- 
tivity necessarily  occasioned  by  these  machines,  is  produdlive 
of  disadvantages  which  are  not  compensated  by  their  good 
effecls.  Apparatus  of  this  kind  are  fitter  for  correcting  vicious 
attitudes  contracted  by  healthy  children,  than  deformity  arising 
from  ricketSo 


197 


CHAPTER  II. 


OF  THE  FRAGILITY  OF  BONES. 

WE  have  seen  that  a  softening  of  the  bones  may  be  pro- 
duced by  a  deficiency  of  phosphate  of  lime:  we  shall 
now  consider  a  disease  of  an  opposite  charafter,  which  con- 
sists in  a  deficiency  of  the  gelatinous  part.  This  substance,  to 
which  bones  owe  their  flexibility,  and  in  which  their  vitality 
resides,  may  be  so  deficient  in  them,  that  they  will  break  on 
the  application  of  yery  slight  causes.  This  disease  has  been 
called  friability,  or  fragility,  from  the  tendency  of  the  bo'-e  to 
crumble  or  fall  in  pieces.  The  state  of  the  bone,  in  this  case, 
may  be  well  conceived  from  that  of  a  calcined  bone. 

This  afi^edtion  is  a  natural  consequence  of  old  age.  The  pro- 
portion of  phosphate  of  lime  deposited  in  the  osseous  tissue, 
increases  as  we  advance  in  life,  and  that  of  the  organized  part 
diminishes  in.a  similar  proportion;  so  that  a  period  arrives  at 
which  the  quantity  of  the  former  so  much  predominates,  that 
the  bones,  dead  as  it  were  before  life  abandons  the  other  parts, 
break  on  the  slightest  occasions. 

The  disease  at  this  period  of  life  is  necessarily  incurable.  If 
the  fractures  be  reduced,  and  an  apparatus  kept  applied  on  the 
limb  for  several  months,  no  progress  towards  consolidation  is 
observed.  Tonics  and  stimulants  are  of  no  use.  There  are  so 
few  vessels  in  the  bones  capable  of  conveying  fluids,  that  no 
granulation  form. 

A  similar  fragility  of  the  bones  is  observed  in  adults;  but  in 
them  it  arises  from  a  venereal,  scrofulous,  or  cancerous  taint. 

When  the  whole  mass  of  fluids  is  infedled  with  the  matter 
of  cancer,  it  sometimes  happens  that  this  virus  attacks  the 
bones,  destroys  their  vital  parts,  and  renders  them  as  brittle 
as  if  they  had  been  calcined.  Saviard  and  Louis  mention  cases 
of  this  kind.  The  latter  relates  the  case  of  a  nun  who  attended 
La  Salpetrierey  who  broke  her  arm  by  simply  leaning  on  a  ser- 
vant as  she  was  entering  a  carriage.  A  very  singular  case  of 
this  kind  is  related  in  the  London  Medical  Journal;  this  un- 


198  OF    THE    FRAGILITY    OF    BONES. 

fortunate  person  could  not  turn  in  bed  without  fracturing  some 
bone. 

This  alarming  symptom  is  completely  irremediable  when  it 
arrives  at  this  stage. 

The  bones  are  sometimes  remarkably  brittle  in  the  latter 
stages  of  syphilis.  In  such  cases  the  primary  disease  claims 
our  chief  attention. 

The  bones  in  the  latter  stages  of  scurvy  become  so  brittle, 
that  they  break  on  slight  occasions,  and  do  not  consolidate  af- 
terwards. Mead  observed,  that  scurvy  was  verv  unfavourable 
to  the  consolidation  of  fradlures,  and  that  in  some  cases  of 
sailors  which  he  observed,  the  callus  was  destroyed  by  scur\'y 
after  it  had  been  formed. 

If  the  bones  of  a  scorbutic  person  be  boiled,  the  periosteum 
separates  very  soon,  lamellae  scale  off,  and,  in  some  cases,  the 
bone  dissolves  entirely.  They  also  fall  into  powder  if  kept  for 
some  time,  but  particularly  if  exposed  alternately  to  heat  and 
moisture. 

We  may  conclude  from  the  preceding  observations,  that 
fragility  is  rather  a  symptom  of  senility,  or  of  some  disease  that 
affefts  the  bones,  by  destroying  their  organic  parts,  than  a  pri- 
mary disease.  We  should  not  have  consigned  a  chapter  to  it, 
did  we  not  hope,  that  the  etiology  of  rickets  may  in  time  be 
elucidated  by  a  comparison  of  these  two  affedtions. 


199 


CHAPTER  III. 


OF  SPRAINS. 

SPRAIN  may  be  defined,  a  more  or  less  violent  tension  of 
the  ligaments  and  other  soft  parts  surrounding  an  articu- 
lation; the  tension  may  be  carried  so  fap  as  to  burst  and  lacerate 
many  of  the  ligaments.  All  the  articulations  are  not  equally 
liable  to  this  accident;  those  which  admit  of  an  extensive  and 
free  motion,  all  the  round  or  loose  articulations,  in  which  the 
bone  moves  in  a  variety  of  diredlions,  as  the  articulation  of  the 
OS  humeri  with  the  scapula,  and  that  of  the  femur  with  the 
ossa  innominata,  are  very  little  subject  to  it.  The  latitude  of 
motion  they  admit  of,  the  small  number,  laxity,  and  parti- 
cular stru<n:ure  of  their  ligaments,  render  them  more  liable  to 
luxations  from  inconsiderable  efforts,  than  to  sprains.  In  the 
articulations  by  ginglymus,  on  the  contrary,  in  which  the  mo- 
tion is  confined  to  two  ways  by  the  reciprocal  conformation  of 
the  surfaces  of  the  joint,  and  by  strong  and  numerous  liga- 
ments, sprains  take  place  often er  than  luxations.  Of  this 
kind  of  articulation  is  that  of  the  foot  with  the  leg,  in  which 
the  astragalus,  received  like  a  tenon  into  a  quadrangular  cavity, 
is  surrounded  on  all  sides  by  very  strong  Hgaments.  Next  to 
the  articulation  of  the  foot  comes  that  of  the  wrist,  then  those 
of  the  knee  and  elbow,  in  which  a  sprain  rarely  occurs. 

The  nature  of  the  affection  may  be  thus  explained:  suppose 
the  foot  or  hand  to  be  fixed,  and  the  leg  or  fore-arm  pushed 
forwards  in  any  direction,  the  ligaments  placed  on  the  side 
against  which  these  parts  are  forcibly  propelled,  will  be  put  in 
a  considerable  state  of  tension,  and  strained;  the  tension  may 
be  carried  so  far  as  to  lacerate  the  ligaments,  of  which  there 
have  been  many  instances.  The  tendons,  and  other  soft  parts, 
such  as  the  nerves,  vessels,  and  even  the  skin,  are  overstretched 
and  pained.  Those  parts  placed  on  the  side  towards  which 
the  displaced  bone  tends,  are  more  or  less  injured  in  the  angle 
which  intercepts  the  luxated  bones:  they  experience  a  contusion, 


209 


OF    SPRAINS. 


by  which  the  small  vessels  are  bruised  and  lacerated,  and  a  con- 
siderable ecchymosis  produced.  The  tension  to  which  the 
parts  of  the  joints  are  subjc<Sted  in  sprains,  is  not  then  confined 
to  the  ligaments  alone,  it  extends  to  all  the  parts  in  the  neigh- 
bourhood; this  gives  an  explanation  of  the  sharp  pains  that 
accompany  them,  and  of  the  inflammatory  swelling  which 
succeeds.  In  fa£t,  although  ligaments  are  endowed  with  a 
peculiar  kind  of  sensibility,  which  renders  the  extension  of 
them  painful,  nevertheless,  they  do  not  possess  a  sensibility  so 
exquisite  as  that  the  irritation  of  them  alone  could  cause  so 
much  pain,  and  such  a  considerable  inflammatory  determina- 
tion, as  that  frequently  occasioned  by  a  sprain. 

A  sprain,  then,  in  the  moment  of  its  produflion  or  taking 
place,  consists  only  of  the  tension,  and  sometimes  laceration 
of  the  soft  parts  surrounding  an  articulation;  but  the  pain 
which  arises  from  it,  quickly  determines  the  fluids  to  the  irri- 
tated part;  a  swelling  more  or  less  considerable  supervenes; 
the  skin  often  appears  black,  livid,  and  spotted,  from  the  in- 
filtration of  the  blood  which  escapes  from  the  ruptured  vessels 
into  the  cellular  texture. 

When  both  parts  of  the  affe(5led  articulation  are  formed  of 
many  bones,  it  may  happen  that  the  ligaments  which  unite 
them  may  be  torn,  and  the  extremities  of  the  articulations 
disjointed  and  separated  from  one  another.  This  diastasis  haS 
been  observed  in  the  inferior  extremities  of  the  tibia  and  fibula, 
in  those  of  the  radius  and  ulna. 

When  the  sprain  is  slight,  the  pain  produced  by  it  gradually 
diminishes,  the  sv^'elling  is  resolved,  the  ecchymosis  extends 
and  disappears,  the  motion  of  the  parts  becomes  easy,  and  at 
the  end  of  some  days  the  articulation  is  restored  to  its  natural 
state.  Nevertheless,  if  the  sprain  has  been  considerable,  and 
especially  if  very  strong  ligaments,  such  as  the  internal  liga- 
ments of  the  articulation  of  the  foot  with  the  leg,  have  been 
partially  or  entirely  torn,  nature  requires  a  considerable  time 
to  unite  the  divided  part;  the  joint  with  difficulty  acquires 
strength,  and  a  feebleness  remains  in  it,  which  disposes  it  to 
the  same  accident. 

A  sprain  is  easily  distinguished  by  attending  to  the  history 
of  the  circumstances  relating  to  it,  such  as  a  fall  or  false  step, 
in  which  the  foot  or  wrist,  as  the  vulgar  say,  has  been  more 
or  less  wrenched.  The  state  of  the  articulation  that  has  suf- 
fered, ought  however  to  be  attentively  examined,  in  order  to 
discover  if  the  ligaments  have  been  lacerated,  or  If  a  disloca- 


OF    SPRAINS.  201 

tion  of  the  extremities  of  the  joint  be  combined  with  the  sprain. 
When  the  parts  admit  of  motion  in  every  direction,  however 
difficult  and  painful  it  may  be,  we  conclude  that  a  simple 
sprain,  and  not  luxation,  has  taken  place. 

The  prog:nosis  is  unfavourable,  in  proportion  as  the  extension 
and  laceration  have  been  considerable.  In  scrofulous  persons 
sprains  are  very  dangerous,  because  they  often  give  rise  to 
white  swellings. 

The  treatment  of  sprains  varies  according  to  the  continuance 
of  the  affecHiion.  Should  the  surgeon  be  called  in  on  the  mo- 
ment that  the  sprain  has  taken  place,  he  should  endeavour  to 
prevent  the  effefts  of  the  irritation  caused  in  the  strained  joint. 
For  this  purpose  the  diseased  part  is  to  be  plunged  into  cold 
water,  or  still  better  into  powdered  ice.  The  brisk  impression 
occasioned  by  the  cold,  constriiSts  all  the  parts,  and  diminishes 
the  diameter  of  all  the  small  vessels,  so  much,  as  to  prevent 
the  admission  of  the  blood  determined  to  them  by  tlie  irrita- 
tion. Besides,  the  extreme  cold,  by  diminishing  sensibility, 
abates  the  irritation  itself,  and  thus  in  two  ways  prevents  the 
influx  of  fluids.  But  to  derive  from  refrigerants  all  the  advan- 
tages that  may  be  expected,  it  is  not  enough  to  leave  the  dis- 
eased part  exposed  to  them  for  half  an  hour,  or  even  an  hour; 
it  must  remain  immersed  in  them  during  several  hours,  and 
they  must  be  renewed  as  they  acquire  heat,  so  that  their  adllon, 
at  once  repellant  and  sedative^  may  preserve  the  same  energy. 
These  means,  if  not  continued  for  a  certain  length  of  time,  far 
from  being  useful,  do  an  injury,  by  exciting  a  reaclion  which 
determines  the  humours  to  the  part  where  the  irritation  had 
already  too  powerfully  invited  them.  Should  a  woman  have 
her  menses  when  this  accident  happens,  these  means  could  not 
be  had  recourse  toj  the  immersion  in  cold  water  would  almost 
infallibly  suppress  the  menstrual  discharge,  and  induce  a  disease 
more  grievous  than  the  sprain  itself.  The  same  would  be  the 
case  should  we  have  to  treat  a  person  with  delicate  lungs. 
"When  the  part  is  reipoved  from  the  ice,  it  must  be  covered 
with  cloths  soaked  in  cold  liquids,  such  as  vegeto-minoral 
water,  spirit  in  which  camphor  or  sal  ammoniac  has  been  dis- 
solved, a  mixture  of  vinegar  and  water.  Sec.  with  which  the 
part  is  to  be  continually  moistened.  By  a  treatment  of  this 
kind,  a  violent  sprain  often  produces  only  a  very  moderate 
swelling,  and  the  disagreeable  consequences  are  never  com- 
pletely developed. 


'202  OF    SPRAINS. 

It  is  scarcely  necessary  to  condemn  here  the  absurd  praftice 
of  ignorant  bone-setters,  Avho  agitate,  twist,  and  press  the 
affe^ed  joint  in  every  direftion,  or  advise  the  patient  to  roll  a 
cylinder  of  wood  under  the  sole  of  the  diseased  foot.  The 
repellent  mode  of  treatment  can  be  successful  only  shortly  after 
the  accident  has  taken  place;  at  the  end  of  twelve  hours,  the 
irritation  which  has  not  been  subdued,  and  the  efFefts  of  which 
have  not  been  prevented,  has  already  produced  an  influx  of 
humours,  with  swelling,  pain,  and  inflammatory  tension  of  the 
adjacent  parts.  It  then  becomes  necessary  to  take  a  quantity 
of  blood  proportioned  to  the  age  and  temperament  of  the  pa- 
tient, the  degree  of  the  sprain,  and  severity  of  the  symptoms. 

Emollient  cataplasms  are  applied,  with  the  view  of  relaxing 
the  Solids,  and  of  abating  irritation;  the  use  of  them  is  to  be 
continued  as  long  as  the  inflammatory  teasion  and  pain  are  pre- 
sent; but  when  the  swelling  begins  to  be  resolved,  which 
change  is  announced  by  the  subsiding  of  the  tumour,  the 
wrinkling  of  the  skin,  the  extension  of  the  ecchymosis  over 
the  limb,  which  becomes  yellow,  resolvents  are  to  be  combined 
with  the  emollients:  for  this  purpose  a  poultice  composed  of 
crumbs  of  bread  and  linseed  meal  boiled  in  wine,  or  in  a  strong 
decodlion  of  elder-flowers,  is  applied;  the  cataplasms  are  to  be 
rendered  more  and  more  resolvent,  and  towards  the  end  of 
the  complaint,  resolvents  only  are  to  be  used:  lastl)',  solvents, 
such  as  styr ax-plaster,  sprinkled  over  with  the  flower  cf  sulphur^ 
&c.  Sec.  are  to  be  substituted  for  them,  and  pumpings  with 
"water  in  which  some  sulphuret  of  potash  has  been  dissolved, 
ov  with  natural  or  artificial  warm  waters,  are  to  be  prescribed. 

The  diseased  part  must  be  kept  in  a  total  state  of  inaction 
for  as  long  time  as  possible,  and  the  limb  preserved  in  the  ho- 
rizontal posture,  which  favours  the  subsiding  of  the  tumour, 
by  facilitating  the  return  of  the  fluids.  The  patient  should  not 
be  allowed  to  walk,  or  make  use  of  his  wrist,  until  the  pain 
has  entirely  vanished;  he  should  even  be  informed  that  the 
pains  will  return,  and  be  felt  at  intervals  for  six  months  or  a 
year,  and  also  advised  not  to  fatigue  too  much  the  weak  joint. 
A  roller  is  to  be  firmly  passed  round  the  foot  and  leg:  by  this 
precaution  the  cedematous  swelling  of  the  limb  will  be  pre- 
vented, which,  without  it,  would  inevitably  take  place.  This 
treatment  is  indispensably  necessary,  when  the  sprain  is  accom- 
panied with  a  complete  or  incomplete  rupture  of  some  liga- 
ment, and  with  the  separation  or  diastasis  of  the  ends  of  the 


OF    SPRAINS.  203 

joint,  a  coiTipHcation  which  renders  the  cases  more  serious,  and 
the  cure  more  tedious  and  difficult. 

If  the  sprain  be  badly  treated,  or  if  the  patient  use  the  af- 
fedled  joint  before  all  the  symptoms  entirely  disappear,  some 
swelling  still  remains  in  the  part;  soon,  in  consequence  of 
some  stress,  the  pains  that  were  only  lulled,  re-appear,  the 
swelling  increases,  but  in  a  slow  manner,  and  assumes  the  ap- 
pearance rather  of  an  indolent  than  inflammatory  tumour, 
being  very  hard  and  without  any  change  of  colour  in  the  skin; 
and  in  rime  it  extends  to  all  the  ligaments  and  soft  parts  in  the 
neighbourhood  of  the  joint.  The  healthiest  and  most  robust 
persons  may  have  tumours  of  this  kind  supervene,  as  the  conse- 
quence of  ill-treated  sprains.  Nevertheless  it  is  certain,  that 
the  existence  of  a  scrofulous  diathesis  gives  a  strong  predisposi- 
tion to  them:  in  this  latter  case,  the  sprain  may  be  considered 
the  exciting  cause  of  the  disease,  which  attacks  an  enfeebled 
and  pained  part  predisposed  to  it.  However,  sprains  that  have 
been  negledled,  often  render  amputation  necessary,  on  account 
of  the  enlargement  and  caries  of  the  bones  that  succeed  to 
them. 

It  may  suffice  for  us  to  say,  without  giving  the  particulars 
of  numerous  instances  of  this  melancholy  termination,  that 
sprain,  an  afFeftion  so  trifling  in  the  eyes  of  the  vulgar,  is  one 
of  the  most  frequent  causes  of  diseases  of  the  joints,  which,  in 
civil  hospitals,  render  amputation  necessary. 

The  rules  to  be  followed  in  the  treatment  of  the  bad  symp- 
toms succeeding  to  sprains,  will  be  given  in  the  chapter  on 
white  swellings.  To  give  them  here,  would  put  us  under  the 
Necessity  of  making  useless  repetitions. 


204 


CHAPTER  IV. 


0|!'  LUXATIONS  IN  GENERAL. 


LUXATION  takes  place  every  time  that  the  articular  ex- 
tremities of  bones  abandon  their  natural  relations,  whe- 
ther it  be  that  the  head  of  a  bone  escapes  from  a  cavity  destined 
to  receive  it,  or  that  the  surfaces  of  the  joint  cease  to  corres- 
pond one  to  the  other.  The  dislocation  may  be  either  total  or 
partial:  hence  luxations  are  divided  into  complete  and  incom- 
plete. 

In  order  to  consider  the  nature  of  luxations,  a  previous  know- 
ledge of  the  anatomy  of  the  articulations,  and  of  the  different 
modes  of  the  junftion  of  bones,  is  necessary.  Thus,  to  form  a 
just  idea  of  the  different  kinds  of  luxation  of  which  the  bone  is 
susceptible,  of  the  manner  in  which  it  takes  place,  to  under- 
stand perfe«^ly  its  symptoms,  easily  seize  the  indications  of 
cure,  and  make  choice  of  the  proper  means  of  fulfilling  them, 
the  particular  conformation,  and  mutual  or  reciprocal  relation 
of  the  surfaces  by  which  the  bones  conie  in  contacl,  and  are 
articulated,  must  be  previously  known.  These  relations  should 
be  learnt  on  fresh  bones  covered  with  their  cartilages,  and 
having  their  cavities  furnished  with  the  cartilaginous  borders 
which  increase  their  depth,  and  with  the  synovial  glands  which 
furnish  the  liquor  by  which  they  are  moistened. 

It  is  equally  necessary  to  have  correal:  notions  of  the  muscles 
surrounding  the  articulation;  of  the  vessels  and  nerves  in  its 
vicinity;  of  the  motions  of  which  the  joint  is  capable,  and  the 
changes  which  the  soft  parts  and  bony  prominences  undergo 
when  these  movements  are  executed. 

After  having  acquired  this  information,  it  is  necessary  to 
know  that  luxations,  as  well  as  fraftures,  present  characters 
which  are  general  and  common  to  all  luxations,  and  objects 
which  are  peculiar  and  confined  to  each  species. 


OF    THE    DIFFERENCES    OF    LUXATIONS.  iO^ 


SfeCTION   I. 


Of  the  Differ etices  of  Luxations. 

Luxation^,  taken  in  a  general  point  of  view,  differ  from 
one  another  i  Ij  with  respect  to  the  articulation  in  which  they 
take  place  5  2,  the  extent  of  the  dislocation  j  3,  the  direction  in 
which  the  bone  is  displaced;  4,  the  length  of  time  they  have 
continued ;  5,  the  circumstances  which  accompany  them,  and 
which  mark  them  out  as  simple  or  compound;  6,  and  lastly, 
with  respe£t  to  the  cause  that  has  produced  them. 

The  extent  and  variety  of  motion  a  joint  admits  of,  give  the 
measure  of  the  tendency  of  the  bones  composing  it  to  be  lux- 
ated. Thus,  the  round  or  loose  articulations,  such  as  that  of 
the  humerus  with  the  scapula,  are  those  in  which  luxations  are 
most  frequent;  in  the  gingl3'moidal  articulations,  on  the  con- 
trary, which  admit  only  of  motion  in  two  opposite  dire£lionSi 
they  are  very  rare.  The  frequency  of  luxations  in  the  orbicular 
articulations,  and  the  unfrequency  of  them  in  the  ginglymoidal, 
may  be  explained  from  many  circumstances  independent  of 
the  greater  or  less  motion  they  admit  of.  In  the  ginglymoidal, 
the  surfaces  of  the  extremities  of  the  bones  which  come  in 
contact,  and  are  adapted  to  one  another,  are  of  considerable 
extent;  and  when  a  foreign  power  a£ls  on  them,  and  forces 
them  in  contrary  direftions,  they  have  to  describe  a  great  space 
before  dislocation  takes  place;  the  ligaments  which  surround 
them  are  very  numerous  and  strong,  and  the  muscles  placed 
on  their  sides  are  disposed  in  a  manner  to  prevent  their  de- 
rangement. 

With  respeft  to  the  extent  of  the  dislocation,  luxations  are 
distinguished  into  complete  and  inooniplete:  the  latter  denomi- 
nation is  given  them  v/hefi  the  surfaces  of  the  joint  are  yet  iu 
contaft  by  some  points  of  its  cartilages,  without  being  entirely 
displaced,  but  at  the  same  time  not  exa<Stly  corresponding.  In-* 
complete  luxations  take  place  only  in  the  articulations  by  gin- 
glymus,  as  in  those  of  the  foot,  the  knee  and  the  elbov/.  When 
complete  dislocation  takes  place  in  these  parts,  the  fci-ce  that 
has  effected  it  must  have  been  very  great;  thus  luxation  in 
them  is  almost  always  incomplete.     The  same  is  not  the  case 


206  OF    THE    DIFFERENCES    OF    LUXATIONS. 

with  the  orbicular  articulations,  the  greater  number  of  which 
are  susceptible  of  no  other  luxation  than  the  complete. 

If  the  head  of  the  humerus  or  femur  is  forced  on  the  cartila- 
ginous brim  that  surrounds  and  deepens  the  cavity  destined  to 
receive  it,  the  osseous  ball,  covered  with  cartilage,  and  having 
its  surface  smooth  and  lubricated,  comes  in  contadl  with  the 
parts  on  which  it  rests  by  only  a  very  few  points,  and  thus 
either  re-enters  the  cavity  it  has  abandoned,  or  escapes  entirely 
out  of  it:  in  the  latter  case  the  luxation  is  complete. 

There  are  some  articulations,  which,  though  truly  orbicular, 
may  nevertheless  admit  of  incomplete  luxations.  For  instance, 
the  head  of  the  astragalus  may  be  so  displaced  as  only  to  aban- 
don in  a  partial  manner  the  cavity  in  the  posterior  face  of  the 
OS  navicularej  but  in  this  case  the  orbicular  ligament  is  tight, 
very  strong,  and  the  motion  inconsiderable.  In  considering 
fraclures  in  general,  we  have  seen  that  they  could  not,  like 
luxations,  be  distinguished  into  complete  and  incomplete,  the 
latter  denomination  not  being  adapted  to  a  solution  of  conti- 
nuity in  one  of  the  bones  of  the  leg  and  fore-arm.  We  shall 
see,  in  treating  of  luxations  of  the  lower  jaw,  that  some,  on  a 
principal  somewhat  similar,  but  equally  erroneous,  have  wished 
to  call  incomplete  that  in  which  only  one  of  the  processes  of 
the  maxilla  is  displaced  from  the  glenoid  cavity  of  the  os  tem- 
poris.  Lastly,  to  conclude  what  relates-  to  the  extent  of  the 
dislocation,  when  the  head  of  the  bone  has  entirely  escaped 
from  its  cavity,  it  may  still  be  forced  to  a  greater  or  less  dis- 
tance between  the  interstices  of  the  muscles. 

As  to  the  different  directions  in  which  a  bone  may  be  dis- 
placed: in  the  round  articulations  it  may  be  luxated  in  the  di- 
rection of  all  the  radii  that  pass  from  the  centre  of  the  circle 
formed  by  the  circumference  of  the  articular  cavity.  There  is 
not,  in  faCt,  a  point  of  the  edge  of  the  glenoid  cavity,  by  which 
the  humerus  may  not  escape.  Nevertheless,  as  shall  be  ex- 
plained when  wc  treat  of  particular  luxations,  various  circum- 
stances depending  en  conformation  cause  the  luxation  to  take 
place  in  certain  dire<5tions  ascertained  by  observation,  so  that 
the  varieties  of  luxations  distinguished  by  the  course  of  the 
displaced  bone  are  much  less  numerous  than  might  at  first  be 
supposed.  Luxations  are  named,  superior,  inferior,  anterior, 
posterior,  S:c.  according  to  the  approximation  of  the  bone  to 
these  directions.  With  respect  to  the  ginglymoidal  articula- 
tions, which,  as  we  have  seen,  constitute  a  class  entirely  diffe- 
rent from  the  orbicular,  considered  in  v/h?.:  rdatrs  to  their 


OF    THE    CAUSES    OF    LUXATIONS.  IQ-J 

luxations  as  well  as  their  motions,  the  bones  which  form  them 
describe  two  lines,  during  their  luxation,  which  cross  one 
another  at  right  angles-,  the  first  by  passing  from  one  side  to 
the  other,  the  second  from  the  anterior  to  the  posterior  part. 

The  continuance  of  luxations  constitutes  a  difference  of  the 
highest  importance,  and  influences  considerably  the  manner  of 
treating  them.  In  faft,  the  reduction  of  a  luxated  bone  which 
has  remained  so  for  several  days,  is  much  more  difficult  than 
that  of  one  more  recently  displaced. 

The  soft  parts,  and  the  bone  itself,  have  acquired  a  certain 
position,  and  the  ligaments  and  muscles  surrounding  the  dis- 
eased joint  become  stiff,  and  difficultly  yield  to  the  efforts  made 
to  reduce  the  bone.  If  a  certain  number  of  days  have  elapsed, 
the  laceration  in  the  ligaments  may  be  so  far  cicatrized  as  to 
render  the  redu<5l:ion  impossible.  Lastly,  the  extremities  of 
the  joint  may  be  grown  to  the  bones  against  which  they  have 
been  forced. 

A  luxation  may  be  simple,  that  is  to  say,  consist  only  of 
the  reciprocal  abandoning  of  the  surfaces  of  the  joint,  and  the 
laceration  of  the  ligaments  which  is  inseparable  from  it ;  it  may 
be  complicated  with  greater  or  less  contusion,  with  a  wound, 
fracture,  or  rupture  of  a  blood-vessel,  and  consequently  an  ef- 
fusion of  blood  into  the  cellular  substance,  with  contvfsion  of  a 
considerable  nerve,  and  a  paralysis  of  the  organs  to  which  It  is 
distributed,  &c.  &o. 


SECTION    II. 


Of  the  Causes  of  Luxations. 

The  causes  may  be  divided  into  external  and  Internal:  both 
are  predisposing  or  occasional. 

The  predisposition  to  luxation  may  depend  on  circumstances 
natural  or  accidental.  The  natural  are,  the  joint  admitting  of 
great  latitude  of  motion,  the  small  extent  of  surfaces  by  which 
the  bones  come  in  conta£l,  the  laxity  and  small  number  of  the 
ligaments  uniting  them,  the  weakness  of  one  side  of  an  articu- 
lation, arising,  for  Instance,  from  a  great  notch  on  one  side, 
as  Is  observed  In  the  interior  and  inferior  part  of  the  acetabulum. 
Disease,  such  as  a  paralysis  of  the  muscles  v»'hich  surround  an 


208  OF    THE    CAUSES    OF    LUXATIONS. 

articulation,  a  debility  and  relaxation  of  its  liganDents,  give  zhih 
a  predisposition  In  a  paralysis  of  the  deltoid  muscle,  tiie 
weight  of  the  arm  alone  has  been  known  to  occasion  an  "lon- 
gation  and  gradual  relaxation  of  the  round  ligament  of  the  ar- 
ticulation of  the  humerus  with  the  scapula,  and  remove  the 
head  of  the  former  bone  to  the  distance  of  two  or  three  inches 
from  the  glenoid  cavity.  I  have  observed  in  a  child,  who  la- 
boured under  an  atrophia  of  the  muscles  of  the  arm  an  empty 
space  of  nearly  an  inch  between  the  head  of  the  bone  and  the 
surface  of  the  cavity,  which  could  be  distin£lly  felt  through  the 
emaciated  deltoid  muscle. 

Sometimes  the  relaxation  of  the  ligaments  appears  without 
any  evident  cause,  and  gives  such  a  disposition  to  luxations, 
that  they  take  place  fron.i  the  slightest  causes:  such  was  the 
case  of  a  woman,  who  could  not  yawn  even  moderately  with- 
out luxating  the  lower  jaw.  It  rxiay  not  be  amiss  to  observe, 
that  these  luxations,  depending  on  the  excessive  relaxation  of 
the  ligaments,  are,  on  accoimt  of  the  relaxation  itself,  very 
easily  reduced, 

A  swelling  or  distension  of  the  cartilages  of  the  joints  and 
caries  of  the  bones,  may  also  dispose  to  luxations;  but  in  these 
cases,  the  affection  of  the  cartilages  and  the  caries  constitute  a 
particulaV  and  primary  disease.  Luxation  is  to  be  considered 
then  only  as  an  additional  symptom;  and  it  is  perhaps  without 
foundation,  as  shall  be  mentioned  in  the  db^pteron  spontane- 
ous luxations  of  the  femur,  that  authors  have  ran.ked  this  dis- 
ease of  the  hip  among  these  afFeftions. 

In  order  that  external  violence,  a  blow,  a  fail,  or  even  the 
a£lion  of  the  muscles,  produce  luxation  in  a  round  articulation, 
the  axis  of  the  bone  must  be  placed  in  a  direcStion  more  or  less 
oblique  with  respe<ft  to  the  surface  with  which  it  is  articulated. 
If,  for  example,  the  os  humeri  hang  exaclly  along  the  sides  of 
the  body,  or  perpendicularly  with  respe(fi:  to  the  glenoid  cavity 
of  the  scapula,  no  force  is  capable  of  luxating  it.  If  a  person 
fall  on  the  elbow  while  the  fore-arm  is  in  this  position,  the 
head  of  the  humerus  will  be  forced  against  the  cavity  formed 
to  receive  it;  but  if  the  arm  be  removed  from  the  body,  the 
axis  of  the  os  humeri  will  fall  obliquely  on  the  surface  of  the 
glenoid  cavity,  which  will  favour  Its  passing  out  of  the  socket; 
and  this  disposition  to  luxate  will  be  increased  in  proportion  as 
the  angle  formed  by  the  axis  of  the  bone  with  the  surface  of  the 
cavity  deviates  from  a  right  angle. 


OF    THE    SYMPTOMS    OF    LUXATION.  20CJ 

A  fall,  or  any  other  kind  of  external  violence,  may  cause  a 
luxation  almost  always  incomplete  in  the  ginglymoidal  articula- 
tions; but  in  the  round  articulations,  the  action  of  the  nauscles 
has  constantly  a  share.  Thus,  for  instance,  if  a  person  fall  on 
the  elbow  whilst  the  arm  is  raised  from  the  body  and  carried 
directly  outwards,  the  shock  which  this  part  receives  will  cer- 
tainly tend  very  much  to  force  the  head  of  the  humerus  out  of 
its  cavity  on  the  lower  and  internal  side;  but  the  action  of  the 
pectoralis  major,  latissimus  dorsi,  and  teres  major,  contributes 
very  much  to  it.  In  faft,  the  elbow,  resting  on  the  ground, 
becomes  the  fulcrum,  or  centre  of  motion  of  the  humerus;  in 
this  state  we  obey  a  mechanical  instindt,  which  leads  us  sud- 
denly to  bring  the  arm  close  to  the  body;  and  as  the  resistance 
made  by  the  ground  prevents  this,  the  violent  and  instantane- 
ous contraction  of  the  pectoralis  major,  latissimus  dorsi,  and 
teres  major,  draws  downwards  and  inwards  the  head  of  the 
humerus,  the  luxation  of  which  is,  as  we  have  demonstrated, 
the  efFe(St  of  two  causes. 

In  this  instance,  we  have  seen  how  muscular  a£tion  conduces 
to  luxations  in  the  round  articulations;  in  some  cases,  this  ac- 
tion alone  is  sufficient  to  effedt  them.  It  is  in  this  way  that 
■violent  convulsions  produce  luxations  as  well  as  fractures. 

Whatever  may  be  the  manner  in  which  the  causes  a<ft,  lux- 
ations are  always  accompanied  with  more  or  less  laceration  of 
the  ligaments  surrounding  the  joint;  and  in  the  round  articu- 
lations, as  those  of  the  shoulder  and  hip,  the  fibrous  capsules 
are  always  torn. 


SECTION   III. 


Of  tie  Symptoms  of  Luxaito:i. 

We  will  not  mention  pain  and  inability  of  moving  the  limb, 
as  they  are  equivocal  symptoms,  and  common  to  luxations, 
fractures,  and  simple  contusion.  They  are  not,  however,  to 
be  entirely  overlooked;  but  when  we  make  a  diagnosis,  we 
should  endeavour  to  found  it  on  the  existence  of  symptoms 
manifest  to  the  senses,  such  as  an  elongation  or  shortening  of 
the  limb,  a  change  in  its  shape  and  direction,  and  lastly,  the 
absolute  impossibility  of  performing  certain  motions.  We  will 
'07 


2IO      OF  THE  SYMPTOMS  OF  LUXATION. 

say  little  on  the  manner  of  ascertaining  the  existence  of  these 
different  symptoms,  as  we  have  already  spoken  of  it  in  giving 
the  general  history  of  fractures. 

A  luxation  cannot  possibly  exist  without  the  afFe£led  limb 
being  either  lengthened,  as  happens  in  the  inferior  extremity, 
■when  the  head  of  the  femur  passes  out  downwards  and  inwards, 
and  rests  in  the  foramen  ovale,  or  shortened,  as  takes  place 
when  the  same  bone  is  luxated  upwards  and  backwards,  and 
has  its  superior  extremity  directed  towards  the  external  depres- 
sion in  the  ilium.  In  truth,  the  shortening  or  elongation  is 
rarely  observed  but  in  the  oi'bicular  articulations;  however,  the 
absence  of  these  symptoms  in  the  ginglymoidal  is  amply  com- 
pensated by  the  superficial  situation  of  the  bones,  which  ren- 
ders it  easy  to  ascertain  their  relative  positions. 

The  dire£lion  of  the  bone  is  changed:  for  the  luxated  end 
cannot  leave  its  natural  place  without  having  the  other  carried 
in  a  direction  contrary  to  it.  Thus,  in  the  luxation  of  the  hu- 
merus downwards  and  inwards,  the  arm  is  placed  obliquely 
downwards  and  outwards,  instead  of  falling  straight  along  the 
side.  This  symptom,  taken  from  the  diredlion  of  the  member, 
is,  like  many  others,  much  easier  to  be  distinguished  in  recent 
luxations  than  in  those  that  have  continued  for  a  considerable 
time.  From  the  change  of  situation  and  direction  of  the  bone, 
there  must  necessarily  result  a  relaxation  of  some  muscles, 
whilst  others  are  considerably  overstretched  and  strained,  as 
may  be  seen  with  respecl  to  the  deltoid  muscle  in  cases  of  lux- 
ations of  the  humerus,  which  are  the  most  frequent.  This 
unequal  and  unnatural  tension  and  relaxation  of  the  muscles  may 
C9ntribute  also  in  aiding  us  to  form  a  diagnosis  in  cases  of  lux- 
ation. 

The  change  in  the  shape  of  the  limb  is  also  removed  by  time. 
In  fadl,  one  would  presume,  from  the  manner  in  which  the 
shape  of  the  point  of  the  shoulder  is  restored  after  a  luxation  of 
the  humerus  by  a  projection  of  bone  arising  from  the  convex 
edge  of  the  acramion,  that  the  head  of  the  cs  humeri  was  not 
forced  Into  the  axilla.  In  these  alterations  of  the  natural  shape 
of  the  limbs,  we  are  to  comprehend  the  changed  relations  of 
the  eminences  of  a  joint  to  one  another,  the  existence  of  pro- 
jeftions  in  places  where  the  limb  should  present  depressions, 
and  depressions  where  it  should  present  eminences.  In  the 
luxation  of  the  arm  inwards  and  downwards,  a  hard  tumour  is 
felt  in  the  axilla,  which,  on  account  of  its  roundness,  is  easily 
ascertained  to  be  this  part  of  the  bone. 


OF    THE    PROGNOSIS    IN    LUXATIONS.  211 

Our  limbs,  even  when  fradtured,  may  be  made  to  perform 
several  motions,  and  be  put  in  various  attitudes.  In  a  fracture 
of  the  femur,  the  surgeon,  not  in  truth  without  causing  more 
or  less  pain  to  the  patient,  may,  by  taking  hold  of  the  leg, 
move  it  round  in  a  circular  diredtion,  and  may  point  the  foot 
inwards  and  outwards — motions  altogether  impossible  in  luxa- 
tions, before  the  reduction  of  the  displaced  bone. 

By  combining  all  these  symptoms,  it  is  impossible  to  form  a 
wrong  diagnosis  in  cases  of  luxation.  A  mistake  would  be  ex- 
tremely dangerous;  for  if  the  luxation  be  not  discovered,  the 
patient  attributes  his  not  being  able  to  use  his  limb  to  the  con- 
tusion and  pain;  but  if  the  continuance  of  the  symptoms  in- 
duce him  to  have  recourse  to  other  persons  better  instruifted  or 
more  attentive,  they  ascertain  the  nature  of  the  affe6lion,  to 
the  no  small  shame  of  the  surgeon  who  has  mistaken  it.  In- 
stances of  errors  of  this  kind  are  more  frequent  than  one  would 
imagine,  especially  in  the  country,  where  the  branch  of  surgery 
which  we  treat  of  in  this  work  is  often  in  the  hands  of  ignorant 
persons. 


SECTION    IV. 


Of  the  Prognosis  in  Luxations. 

The  luxations  which  take  place  in  the  ginglymoidal  articu- 
lations, differ  much  from  those  in  round  articulations,  in  what 
relates  to  prognosis,  as  well  as  in  many  other  points  of  view: 
the  latter  are  much  less  dangerous  than  the  former.  As  the 
adlion  of  muscles  has  a  great  share  in  producing  them,  the  vio- 
lence done  to  the  external  parts  is  less,  and  the  laceration  of 
the  soft  parts  is  not  so  considerable:  even  in  articulations  of  the 
same  kind,  the  extent  of  the  evil  is  measured  by  the  largeness 
of  the  surfaces  of  the  joint,  the  number  and  strength  of  the 
muscles  surrounding  it,  and  the  thickness  and  number  of  its 
ligaments.  It  is  for  these  reasons  that  luxations  of  the  foot 
and  knee  are  more  dangerous  than  those  of  the  elbow  and 
wrist:  the  former  require  a  much  greater  degree  of  external 
violence  to  produce  them,  in  consequence  of  which  the  injury 
done  to  the  soft  parts  is  much  greater. 


212     GENERAL  TREATMENT  OF  LUXATIONS. 

A  difficulty  in  reducing  the  luxated  bone  renders  the  luxa- 
tion more  or  less  troublesome.  With  respeft  to  this  point, 
luxations  of  the  round  articulations  are  more  unfavourable  than 
those  of  the  ginglymoidal;  those  of  the  femur  more  than  those 
of  the  humerus,  because  the  efforts  to  reduce  the  former  are 
often  counteracted  by  the  action  of  very  powerful  muscles. 

Luxations  arising  from  a  swelling  of  the  cartilages  of  the 
joints,  from  a  caries  of  the  bones,  or  from  a  relaxation  of  the 
ligaments,  are  always  attended  by  more  grievous  consequences 
than  those  occasioned  by  external  violence.  Lastly,  a  contusion 
more  or  less  considerable,  laceration  of  vessels,  or  destruftion 
of  the  substance  of  nerves,  render  the  prognosis  more  or  less 
unfavourable.  The  latter  circumstance  occasions  a  paralysis  of 
the  muscles  to  which  the  disorganized  nerve  furnished  branches. 
We  have  seen,  in  a  luxation  of  the  humerus  downwards  and 
inwards,  a  paralysis  of  the  deltoid  muscle  produced  by  the  vio- 
lent contusion  of  the  circumflex  nerve,  which  is  chiefly  be- 
stowed on  that  muscle. 


SECTION  V- 


General  Treatment  of  Luxations. 

To  reduce  the  luxated  bone,  keep  it  in  its  place,  and  prer, 
vent  or  remove  the  symptoms  with  which  the  luxation  may 
be  complicated,  form  the  three  indications  which  are  to  be 
fulfilled  in  the  treatment  of  luxations.  The  reduction  is  ac- 
complished, as  in  cases  of  frafture,  by  three  means  opposite  in 
their  aftion,  but  tending  to  the  same  end,  viz.  extension,  coun- 
ter-extension, and  co-aptation.  It  is  useless  to  repeat  the  de- 
-finition  of  each  of  these  terms,  and  in  what  each  of  these  mo- 
tions consisits. 

The  reduction  of  a  luxation  is  the  most  difficult  and  import- 
ant part  of  the  treatment  of  it.  Contrary  to  Avhat  takes  place 
in  fra6tures,  which  are  easily  reduced,  but  difficultly  kept  so, 
luxations  are  hard  to  reduce;  but  when  the  bone  is  once  ad- 
justed, it  is  easily  kept  in  its  place.  It  will  not  then  be  useless 
to  examine  minutely  all  the  particulars  of  this  operation:  and 
first,  with  respe^  to  extension,  we  will  examine  in  order  on 
wliat  part  the  apparatus  for  making  it  should  be  applied,  the 


GENERAI,  TREATMENT  OF  LUXATIONS.     21^ 

means  employed  for  this  purpose,  the  degree  of  force  to  be 
used,  and  the  direction  in  which  it  is  to  be  made. 

The  extending  force  should  be  applied,  not  on  the  luxated 
bone,  but  on  that  with  which  it  is  articulated,  and  as  far  as 
possible  from  it.  The  observance  of  this  precept  is  still  more 
necessary  in  luxations  than  in  fradtures. 

All  the  ancient  authors  advised  applying  the  extending  force 
on  the  luxated  bone;  for  instance,  to  apply  it  above  the  knee 
in  luxations  of  the  femur,  and  above  the  elbow  in  those  of  the 
humerus.  Many  of  the  moderns  have  followed  their  instruc- 
tions; and  this  mode  is  found  recommended  by  J  L.  Petit  and 
Duverney,  in  their  Treatises  on  the  Diseases  of  the  Bones. 
Two  members  of  the  Academy  of  Surgery,  Fabre  and  Dupouy, 
saw  the  inconvenience  of  this  practice,  and  substituted  for  it  a 
mode  of  treatment  now  generally  adopted.  Their  practice, 
which  consists  in  applying  the  extending  force  on  the  bone  that 
articulates  with  the  luxated  one,  has  two  most  important  ad- 
vantages: first,  the  muscles  that  surround  the  luxated  bone  are 
not  compressed,  nor  stimulated  to  spasmodic  contradlions,  which 
would  prevent  the  reduction,  not  only  by  opposing  a  force  su- 
perior to  that  employed  for  the  purpose  of  reduftion,  but  also 
by  retaining  the  head  of  the  bone  engaged  in  the  interstices  of 
the  contradled  muscles.  Secondly,  the  extending  force  is  much 
more  considerable  than  can  be  obtained  by  the  other  mode;  for, 
as  Dupouy  has  observed,  by  elongating  thus  the  arm  of  the 
lever,  we  acquire  a  degree  of  power,  which  the  difficulties 
presented  in  a  great  number  of  cases  often  force  us  to  have  re- 
course to. 

It  has  been  apprehended,  it  is  true,  that  the  extending  force 
applied  at  a  distance  from  the  luxated  bone,  would  lose  in  the 
articulations  of  the  limb  a  part  of  its  cfFeft:  thus,  it  has  been 
said,  that  a  part  of  the  extending  force  applied  at  the  wrist  in  a 
luxation  of  the  humerus,  is  employed  in  elongating  the  liga- 
ments of  the  elbow  joint.  But  this  objection  is  ill  founded:  all 
the  muscles  which  go  from  the  humerus  to  the  fore-arm,  by 
strengthening  the  articulation  of  these  bones,  make  it  answer 
as  a  continued  lever,  along  whicli  the  force  is  communicated 
without  any  loss. 

Force  applied  by  the  hands  of  intelligent  and  strong  a'ssist- 
ants,  is  preferable  to  any  mechanical  means  in  the  redu£Vion  of 
luxations:  the  number  of  assistants  may  be  increased  at  will, 
and  the  force  proportioned  to  the  resistance  that  is  experienced : 
should  there  not  be  room  for  a  sufficient  number  to  grasp  the 


214    GENERAL  TREATMENT  OF  LUXATIONS. 

limb,  they  may  pull  by  a  napkin  folded  longimdinally,  and 
tied  on  the  limb.  The  quantity  of  force  employed,  though  it 
is  impossible  to  ascertain  it  exailly,  is  better  known  when  we 
make  use  of  a  certain  number  of  assistants,  than  when  we  use 
a  pulley,  which  may  a£t  with  such  force  without  our  perceiving 
it,  as  to  lacerate  the  muscles,  ligaments,  and  even  the  skin 
which  covers  the  articulation,  and  thus  occasion  the  most  dire- 
ful sufferings. 

It  is  impossible  to  assign  the  precise  degree  of  force  to  be 
employed:  it  is  to  be  varied  and  proportioned  according  to  the 
strength  of  the  patient  and  the  number  and  force  of  the  mus- 
cles surrounding  the  articulation.  It  has  been  said,  that  in 
reducing  a  luxation  there  is  occasion  for  more  address  than 
force:  it  would  be  true  to  say  that  the  union  of  both  is  neces- 
sary. Often,  six  assistants  accomplish  that  which  three  cannot 
do,  and  nine  or  ten  perform  that  which  cannot  be  done  by  six. 
But  when  the  redudlion  cannot  be  effedled  by  the  number  of 
assistants  which  in  reason  we  suppose  capable  of  overcoming 
the  resistance,  all  further  attempts  must  be  suspended.  The 
action  of  pullies,  or  any  other  machine  analogous  to  them, 
would  sooner  tear  the  integuments  than  produce  an  elongation 
of  the  muscles. 

As  to  the  direftionin  which  the  extending  force  is  to  be  ap- 
plied: at  first  it  should  be  the  same  as  that  which  the  disloca- 
tion has  given  to  the  luxated  bone.  In  order  to  prove  how 
indispensably  necessary  this  rule  is,  let  us  suppose  that  the 
head  of  the  humerus,  luxated  inwards,  is  forced  into  the  fossa 
subscapularis,  between  the  subscapiilaris  muscle  and  the  scapula: 
in  this  case,  the  elbow  is  not  only  moved  out  from  the  trunk, 
but  even  carried  backwards.  Now,  should  we  commence  the 
reduction  by  pulling  in  the  natural  direction  of  the  humerus,  that 
is,  direffcly  outwards,  the  head  of  the  bone  would  be  pressed, 
against  the  fossa  subscapularis,  it  would  not  slide  along  easily, 
the  force  would  be  spent  in  pushing  the  scapula  backwards,  an4 
the  irritation  would  excite  the  contraction  of  the  muscles  in  the 
part  where  the  head  of  the  bone  has  been  carried. 

Extension  is  then  to  be  made  at  first  in  the  dire£lion  which 
the  luxated  bone  has  taken;  but  in  proportion  as  the  muscles 
elongate  and  yield  to  the  force  acting  on  them,  the  hone  is  to 
be  gradually  brought  back  to  its  natural  position;  in  this  way 
the  head  of  the  bone  is  disengaged  from  the  parts  in  which 
it  has  been  placed,  and  is  brought  hack  to  the  cavity  it  has 


GENERAL  TREATMENT  OF  LUXATIONS.     215 

left,  by  making  it  describe  the  same  course  it  took  in  escaping 
from  it. 

The  best-di reeled  extension  will  be  useless,  if  the  bone 
with  which  the  luxated  one  has  been  articulated  is  not  kept 
motionless  by  counter-extension,  a  force  equal  to  the  other, 
but  made  in  a  contrary  direction.  The  counter-extending 
power  applied  to  the  luxated  bone  itself,  would  be  attended,  in 
almost  every  case,  with  the  double  inconvenience  of  producing 
a  spasmodic  contraction  of  the  muscles,  and  preventing  the 
elongation  of  them  necessary  for  the  reduclion.  Let  us  sup- 
pose that  in  a  luxation  of  the  thigh,  the  counter-extending 
fillet  be  applied  in  the  fold  of  the  groin  of  the  diseased  side, 
the  consequence  will  be,  that  the  redlus  internus  and  addu61:ores 
muscles,  in  a  state  of  tension  between  the  pelvis  and  thigh, 
will  be  curved  inwards,  and  consequently  shortened  when 
their  elongation  is  absolutely  necessary;  besides,  the  compression 
they  experience  will  also  increase  their  contracTtion.  It  must 
be,  then,  as  in  cases  of  fracture,  on  the  part  placed  immediately 
above  the  luxated  bone  that  we  are  to  apply  the  counter-extend- 
ing force:  It  is  made  by  means  of  fillets,  pulled  by  a  number  of 
assistants,  equ?il  to  that  of  those  who  make  the  extension.  As 
to  the  direction  in  which  this  force  is  to  be  made,  it  should  be 
always  perpendicular  to  the  surface  of  ths  luxated  joint.  In  a 
luxation  of  the  elbow,  for  instance,  the  counter-extension  should 
be  made  in  a  line  parallel  to  the  os  humeri;  and  in  a  similar 
aSeelion  of  the  femur,  this  force  applied  to  the  pelyis  should 
be  made  perpendicularly  to  the  surface  of  the  acetabulum.  The 
same  rule  is  to  be  observed  with  respe£l:  to  the  shoulder  in  lux- 
ations of  the  humerus,  as  will  be  mentioned  in  treating  of  par- 
ticular luxations.  Counter-extension  is  in  some  sort  a  vis  iner- 
ticc;  for  this  reason  the  most  intelligent  assistants  should  be 
placed  to  make  extension,  the  degree  of  which  should  be 
diredled  by  the  surgeon.  Coaptation  is  easily  performed,  when 
the  extension  is  sufficient:  in  a  luxation  of  the  humerus,  when 
the  head  of  the  bone  is  disengaged,  and  the  assistants  bring  it 
hastily  to  its  natural  direction,  the  surgeon  seizes  the  moment, 
and  with  one  hand  presses  on  the  superior  and  internal  part  of 
the  arm,  whilst,  at  the  same  time,  with  the  other  he  supports 
the  elbow,  and  thus  conducts  the  head  of  the  bone  into  the 
glenoid  cavity.  If  a  luxation  take  place  in  a  ginglymoidal  arti- 
culation, as  it  is  rarely  complete,  in  such  cases  we  use  exten- 
sion and  counter-extension  only  with  the  view  of  diminishmp" 
the  fridlion  of  the  surfaces  of  the  joint,  necessarily  oceasioned 


2l6    GENERAL  TREATMENT  OF  LUXATIONS. 

by  the  opposite  motions  given  them  in  order  to  place  theni  in 
their  natural  situation. 

By  an  exa£l  observance  of  the  general  rules  just  laid  down, 
we  shall  be  able,  in  almost  all  cases,  to  reduce  luxations.  How- 
ever, when  the  operation  fails,  notwithstanding  the  most  judi»- 
oious  attempts  to  accomplish  it,  the  cause  of  failure  must  be 
looked  for.  Sometimes  it  is  owing  to  the  insufficiency  of  the 
means  employed;  then  we  succeed  by  increasing  the  number 
of  assistants,  or  by  diminishing  the  muscular  force  of  the  pa- 
tient, which  is  done  in  various  ways. 

Change  of  posture  often  produces  this  effeft;  we  have  seen 
patients,  who,  while  seated  on  a  chair,  and  supporting  them- 
selves with  the  feet  against  the  ground,  could  not  have  had 
their  luxations  reduced  by  the  greatest  efforts.  By  extending 
them  on  a  long  and  settled  table,  their  muscles,  deprived  of  a 
centre  of  motion,  yielded  with  an  unexpefted  facility. 

If  this  means  proves  insufficient,  the  patient  is  to  be  repeat- 
edly bled,  after  short  intervals;  he  is  to  use  the  warm  bath, 
and  be  confined  to  a  very  low  diet.  At  the  end  of  twenty- four 
hours,  when  he  is  brought  down  by  this  treatment,  the  luxa- 
tion, before  irreducible  in  appearance,  may  now  be  reduced  with 
facility.  The  state  of  intoxication,  induced  by  spirituous  li- 
quors or  opium,  is  favourable;  the  muscles  attached  to  the 
luxated  bone  participate  in  the  general  debility,  and  elongate 
by  the  slightest  effort.  It  is  thus  that  Citizen  Boyer  alone,  and 
at  the  first  attempt,  while  the  assistants  were  preparing  the 
apparatus,  reduced  a  luxation  of  the  arm  of  an  intoxicated  |J&s- 
tillion.  Some  authors  have  even  advised  to  intoxicate  the  pa- 
tients, when  the  luxations  could  not  be  reduced  by  the  ordinary 
means;  and  cases  have  been  met  with,  in  which  even  this 
pra£lice  has  failed. 

Lastly,  one  more  resource  remains,  v/hich  has  sometimes 
succeeded;  it  was  first  employed  by  Le  Cat,  in  a  luxation  of  the 
jaw,  and  consists  in  fatiguing,  by  continual  action,  the  muscles 
which  surround  the  luxated  bone.  It  is  well  known  that  the 
contra6lile  faculty  of  our  organs  is  exhausted  by  exercising 
them  too  long,  and  that  the  frequent  repetition  of  their  con- 
tractions necessarily  brings  about  a  collapse:  the  surgeon  just 
cited,  availed  himself  of  this  fadt.  The  levatores  muscles 
of  the  lower  jaw  were  spasmodically  contracted,  in  a  case  of 
luxation  of  that  bone,  and  would  not  admit  of  having  it  brought 
down :  Le  Cat  introduced  a  small  stick  between  the  teeth,  and 


GENERAL  TREATMENT  OF  LUXATIONS.    2I7 

making  use  of  it  as  a  lever,  combated  the  a£lion  of  the  muscles, 
until  they  fell  into  a  state  of  atony,  and  allowed  him  to  accom- 
plish the  reduflion.  David  has  derived  similar  advantages  from 
the  same  praftice,  in  luxations  of  the  thigh  and  arm.  This 
circumstance  enables  us  to  explain  why  a  luxation  that  has  re- 
sisted the  fruitless  efforts  of  an  intelligent  surgeon,  aided  by  a 
sufficient  number  of  assistants,  afterwards  yields  to  a  much  less 
considerable  force,  used  by  a  less  dexterous  practitioner. 

With  respeft  to  luxations  that  have  been  mistaken,  and  not 
reduced  for  several  days  after  the  accident;  the  swelling  of  the 
ligaments,  and  other  soft  parts,  the  contradlion  of  the  hole  in 
the  capsule,  through  which  the  head  of  the  bone  passed,  ren- 
der the  redu<5lion  of  them  difficult,  if  not  altogether  impossible. 
The  use  of  warm  baths  arid  pumping  is  then  recommended, 
with  a  view  of  emptying,  as  it  were,  and  rendering  pliable,  the 
parts  about  the  joint:  exercise  should  be  combined  with  these, 
and  the  luxated  bone  should  be  kept  in  motion  for  some  time 
6very  day,  in  order  to  disengage  Its  head,  relax  the  soft  parts, 
and  enlarge  the  opening  by  which  it  is  to  pass. 

All  these  endeavours  are  very  often  fruitless,  In  cases  where 
more  than  a  month  has  elapsed  since  the  luxation.  The  term 
beyond  which  we  cannot  hope  to  reduce  luxations  of  the  gln- 
glymoidal  articulations,  is  ir.uch  shorter;  after  twenty  or  twen- 
ty-four days,  they  are  in  general  irreducible,  from  ari  anchylosis 
having  taken  place. 

We  know  that  a  luxation  Is  reduced  from  the  limb  having  re- 
covered its  natural  length,  shape,  and  diredtion,  and  from  the 
capability  of  performing  certain  motions  impossible  in  luxations. 
The  limb  should  not  be  moved  but  with  the  greatest  caution :  a 
relapse  of  a  luxation  of  the  humerus  has  taken  place,  and  a 
second  operation  has  been  rendered  necessary,  by  incautiously 
carrying  the  hand  to  the  forehead  by  a  semi-circular  motion. 

The  cessation  of  pain  has  been  considered  a  sign  of  the  bone 
having  entered  its  natural  situation:  by  cessation,  we  are  to 
understand  a  remarkable  diminution,  rather  than  a  total  disap- 
pearance of  pain.  Lastly,  the  noise  made  by  the  head  of  the 
bone  on  entering  its  cavity,  is  an  unequivocal  sign  of  the  luxa- 
tion being  reduced.  It  is  necessary  to  observe  all  these  symp- 
toms. In  order  to  be  convinced  that  the  reduftlon  has  taken 
place;  by  doing  so  we  shall  be  seldom  mistaken,  though  in- 
stances to  the  contrary  have  been  sometimes  met  with. 

We  very  rarely  fail  to  reduce  a  recent  luxation,  and  perhaps 
there  are  none  absolutely  irreducible:  thus  we  ought  not  to  be 
28 


2l8     GENERAL  TREATMENT  OF  LUXATIONS. 

discouraged,  and  desist,  when  we  cannot  easily  obtain  the  re- 
du£lion,  but  multiply  our  means,  and  endeavour  to  surmount 
the  obstacles. 

To  preserve  the  luxated  bone  in  its  place,  we  have  only  to 
keep  the  limb  without  motion.  Thus,  as  the  humerus  cannot 
be  luxated  but  when  it  is  at  some  distance  from  the  body,  a 
return  of  its  dislocation  will  be  prevented  by  tying  the  elbow  to 
the  lateral  parts  of  the  trunk.  The  bandage  employed  for 
keeping  the  limb  motionless,  should  be  applied  on  the  oppo^ 
site  extremity  of  the  bone.  Thus,  after  a  luxation  of  the  arm, 
when  we  apply  on  the  elbow  the  means  for  keeping  the  bone 
in  its  place,  we  aft  on  that  point  of  the  humerus  the  most  dis- 
tant from  its  articulation  with  the  scapula,  and  the  force  thus 
applied  to  the  extremity  of  the  lever  is  much  increased.  The 
same  rule  should  be  observed  in  the  application  of  a  bandage 
to  the  chin,  after  a  luxation  of  the  jaw.  This  pradlice  is  pre- 
ferable to  the  use  of  the  chevestre\  consequently  all  authors  re- 
commend it  in  this  particular  case;  but  they  have  overlooked, 
in  other  cases,  the  principle  established  above,  and  from  which 
they  derived  such  happy  efFefts  in  the  treatment  of  luxations 
of  the  jaw.  Thus,  the  spica  bandage  for  the  scapula,  and  that 
for  the  groin,  are  very  defeftive  in  cases  of  luxation  of  the  arm 
and  thigh;  for,  by  afting  on  the  centre  of  motion  of  these 
bones,  they  are  incapable  of  keeping  them  fixed. 

When  the  luxation  arises  from  any  internal  cause,  such  as 
paralysi-  of  the  muscles,  relaxation  of  the  ligaments,  or  general 
debility,  we  endeavour  to  remove  the  cause  by  appropriate  re- 
medies, and,  at  the  same  time,  restore  the  luxated  bone  to  its 
proper  place,  and  keep  it  fixed. 

Amongst  the  accidents  with  which  luxations  are  complicated, 
contusion  is  certainly  the  most  frequent.  They  may  also  be 
accompanied  with  inflammation,  wounds,  rupture  of  vessels, 
contusion  of  nerves,  and  even  frafture.  In  treating  in  general 
of  the  latter,  we  have  said,  that  in  such  case  luxation  always 
preceded  the  fra£lure;  and  that  it  was  impossible  to  conceive, 
that  a  bone,  in  which  a  solution  of  continuity  took  place,  could 
be  luxated.  The  treatment  to  be  adopted  in  this  troublesome 
complication  has  been  also  pointed  out.  The  other  symptoms 
supervening  to  luxations,  are  treated  as  if  they  were  compli- 
cated with  fraftures;  we  have  nothing  then  to  add  to  what  has 
been  said  on  that  subjeft.  It  is  proper,  however,  to  observe, 
that  paralysis,  arising  from  a  contusion  of  the  nerves,  is  a  fre- 
quent consequence  of  luxations  of  the  arm;  and  when  we  con- 


■4- 


GENERAL  TREATMENT  eF  LUXATIONS.     219 

sider  the  relation  between  the  head  of  the  humerus,  and  the 
brachial  plexus,  we  are  astonished  that  it  does  not  happen  of- 
tener  than  it  really  does. 

When  a  luxated  bone  is  not  reduced,  sometimes  it  remains 
in  the  place  into  which  it  has  been  forced  5  but  much  of- 
tener  it  changes  its  situation:  it  is  carried  along  by  the  a£lion 
of  the  muscles,  and  is  removed  farther  and  farther  from  the 
cavity  of  the  joint.  It  is  in  this  way  that  in  luxations  of  the 
thigh  upwards  and  outwards,  the  glutei  muscles,  by  making 
the  convex  surface  of  the  head  of  the  femur  slide  along  the  ex- 
ternal depression  of  the  ilium,  which  it  touches  only  by  a  small 
point,  force  up  the  bone,  until  the  shortening  of  the  limb  is 
as  considerable  as  the  natural  extensibility  of  the  parts  will 
admit. 

But  whether  the  head  of  the  luxated  bone  preserve  its  first 
position,  or  take  another,  the  pressure  it  makes  on  the  bone 
on  which  it  rests  produces  two  efFefts:  the  head  of  the  one  is 
flattened,  while  a  depression  is  made  in  the  other.  The  ca- 
vity of  the  joint  sometimes  preserves  its  natural  state,  and  some- 
times its  depth  diminishes;  the  latter  takes  place  when  the 
head  of  the  bone  remains  near  its  cavity,  and  compresses  the 
circumference  of  it.  The  ligaments  grow  thick,  their  lacera-r 
tions  consolidate,  and  they  acquire  a  greater  consistence  than 
natural.  The  muscles,  impeded  in  their  action,  lose  their 
consistence,  become  of  the  nature  of  ligaments,  and  sometimes 
even  are  attached  to  the  ligaments  by  a  deposition  of  osseous 
matter,  and  thus  form  a  kind  of  bony  case,  which  constitutes 
with  the  displaced  bone  a  new  articulation. 

If  the  bone  is  not  reduced,  the  limb  remains  deformed,  and 
scarcely  any  use  can  be  made  of  it  for  some  months;  but  in  time 
it  gradually  comes  to  its  natural  direction;  and  when  the  head 
of  the  bone  has  acquired  a  certain  mobility  in  its  new  articula- 
tion, it  is  capable  of  considerable  latitude  of  motion.  Never- 
theless, the  muscles,  from  being  compressed  and  obstrudled  in 
their  adtion,  decay,  and  the  size  of  the  limb  diminishes:  this 
diminution  is  much  more  remarkable  in  children  than  in  adults. 

This  difference  is  so  great,  that  it  may  be  distinguished  at 
first  sight  whether  the  accident  happened  during  infancy  or 
maturity. 


M 


220 


CHAPTER  V. 


OF  LUXATIONS  OF  THE  LOWER  JAW. 

THIS  bone  can  only  be  luxated  anteriorly,  whether  one  or 
both  condyles  escape  from  the  glenoid  cavities  of  the 
ossa  temf)orum,  with  which  it  is  articulate-d.  Luxations  of  it 
are  denominated  complete  or  incomplete;  but  these  denomina- 
tions are  erroneous,  as  they  would  lead  us  to  believe,  that  the 
bone  may  be  luxated  without  its  condyles  being'removed  en- 
tirely from  the  glenoid  cavities  of  the  temporal  bones.  Every 
luxation,  but  that  anteriorly,  is  rendered  impossible  by  the 
natural  conformation  of  the  parts.  In  reality,  before  a  luxa- 
tion backwards  could  take  place,  the  maxilla  inferior  must  be 
elevated  above  the  point  of  contact  of  the  arch  formed  by  the 
teeth,  and  meet  no  opposition  to  its  dislocation  in  this  direc- 
tion from  the  osseous  portion  of  the  auditory  canal;  and  further, 
it  must  be  efFefted  without  the  aid  of  any  muscle.  Luxations 
laterally,  to  the  right  or  left,  are  equally  impossible,  on  account 
of  the  resistance  made  by  the  spinous  processes  of  the  sphenoid 
bone,  and  the  internal  ligaments  of  the  articulation.  These 
ligaments,  like  all  the  others  of  the  same  part,  would  in  truth 
afford  a  feeble  resistance;  for  the  muscles  are  here  very  evi- 
dently the  principal  means  of  strengthening  the  articulation: 
but,  independently  of  these  considerations,  it  is  evident,  from 
the  form  of  the  bone,  that  a  blow  given  to  it  ojn  its  sides,  tends 
rather,  by  increasing  its  curvature,  to  fradture  it,  than  to  lux- 
ate it. 

In  very  young  infants,  any  luxation  of  the  jaw  is  impossible  : 
in  thern  the  body  and  branches  of  the  bone  meet  at  an  obtuse 
angle.  Now,  from  this  conformation,  it  follows,  that  the  con- 
dyles, the  necks  of  which  have  nearly  the  same  dire(5tion  as 
the  body  of  the  bone,  cannot,  by  any  motion  of  the  jaw,  be 
moved  out  of  th^ir  cavities;  and,  in  order  to  produce  a  luxa- 
tion, the  jaw  should  be  pulled  down,  and  the  mouth  opened 
to  a  degree  which  it  could  not  admit  of.     Were  it  not  for  this 


OF    LUXATIONS    OF    THE    LOWER    JAW.  Ill 

truly  admirable  disposition,  how  frequent  would  not  luxations 
be  at  this  period  of  life,  either  from  the  cries  of  the  child,  or 
from  attempts  to  put  too  large  bodies  into  its  mouth! 

The  causes  of  luxations  of  the  lower  jaw  are  very  often  in- 
ternal: rarely  has  it  been  seen,  that  a  blow  given  from  above 
downwards,  or  from  before  backwards,  or  a  fall  on  the  chin, 
has  produced  luxation  of  it;  it  almost  always  arises  from  ex- 
cessive yawning.  In  every  great  depression  of  the  jaw,  the 
condyles  slide  from  behind  forwards,  under  the  transverse  root 
of  the  zygomatic  processes.  The  cartilaginous  cap  which  en- 
velops the  condyles,  and  follows  them  in  all  their  motions,  fur- 
nishes to  them  still  an  articular  cavity:  but  the  depression  of 
the  bone  continuing,  the  ligaments  give  way,  the  condyles  pass 
before  the  transverse  apophyses,  and  thus  fall  into  the  zygo- 
matic depressions.  In  this  motion,  the  angles  of  the  jaw  are 
raised  and  carried  backwards,  whilst  the  condyles  are  depressed 
and  carried  forwards*,  and  the  bone,  as  is  well  known,  by  turn- 
ing on  an  axis  which  may  be  supposed  to  pass  through  its 
branches  nearly  about  the  middle  of  their  height,  performs  an 
imperfedl  revolution. 

The  mode  in  which  luxations  of  the  jaw  take  place  has  been 
differently  explained.  Some  have  imagined,  that  the  bone 
being  forcibly  carried  down  by  the  submaxillary  muscles,  and 
carried  forwards  bv  the  pterygoidei  externi,  its  coronoid  apo- 
physes perched  on  the  eminences  of  the  cheek-bone  and  be- 
came a  fixed  point  for  the  adlion  of  the  levatores  muscles, 
which  dragged  the  condyles  into  the  zygomatic  depressions. 
But  to  prove  how  ill-founded  this  theory  is,  it  is  sufficient  to 
observe,  that  in  no  case  is  the  coronoid  apophysis  carried  on 
the  eminence  of  the  cheek  bone,  and  that  even  when  the  lux- 
ation has  taken  place,  an  interval  can  be  still  felt  between  these 
two  bony  parts. 

When  the  mouth  is  shut,  the  axis  of  the  maxilla  inferior  forms 
with  a  Une  drawn  in  the  dire£lion  of  the  middle  of  the  masseter 
muscle,  an  obtuse  angle  anteriorly,  and  a  salient  angle  poste- 
riorly, consequently  when  this  muscle  contrafts,  in  order  to 
move  the  lower  jaw,  its  aftion  is  decomposed,  one  part  tends  to 
elevate  it  perpendicularly,  and  the  other  to  carry  it  forwards. 
In  proportion  as  the  jaw  is  depressed,  and  its  angles,  to  the  ex- 
ternal sides  of  which  the  masseters  are  attached,  are  carried 
upwards  and  backwards,  the  medium  line  of  the  dire(flion  of 
the  bone  tends  to  become  parallel  with  that  of  the  masseters; 
and  if  these  m.usclcs  contrail  when  the  bone  is  in  this  position. 


222  OF    LUXATIONS    OF    THE    LOWER    JAW. 

the  greater  part  of  their  force  is  employed  to  bring  the  condyle*         | 
into  the  zygomatic  depressions. 

This  explanation,  very  little  different  from  that  given  by  '^ 
Citizen  Pinel,*  in  a  Memoir  in  which  he  applies  geometry  to 
explain  the  theory  of  luxations,  appears  to  us  much  better  than 
the  preceding,  which  is  found  in  a  Treatise  on  Diseases  of  th« 
Bones,  and  Surgical  Operations,  by  Chopart  and  Desault.  But, 
whatever  may  be  the  manner  in  which  tne  levatores  of  the  jaw 
produce  a  luxation  of  this  bone  in  its  depressed  state,  the  parts 
which  surround  the  articulation  are  affedled  in  the  following 
manner:  The  condyles  carried  before  the  transverse  root  of  the 
zygomatic  processes  into  the  zygomatic  depressions,  compress 
in  a  greater  or  less  degree  the  deep-seated  temporal  nerves  and 
those  going  to  the  masseters,  which  nerves,  in  their  way  to 
their  destination,  pass  before  the  neck  of  these  processes.  This  a 
compression  of  the  nerves  by  the  condyles,  explains  the  pain 
accompanying  luxation  of  the  jaw  much  more  satisfadlorily,  than 
does  the  elongation  of  the  masseters  and  other  muscles  to  which 
they  have  been  attributed.  The  tension  of  the  masseter,  tem- 
poral and  internal  pterygoid  muscles,  is  not  so  considerable  as  to 
produce  them.  The  pterygoideus  externus  is  relaxed  j  the  fee- 
ble ligaments  which  surround  the  articulation  are  in  a  state  of 
tension,  the  interarticular  cartilages  accompany  the  condyles, 
and  furnish  them,  even  in  the  zygomatic  depressions  with  a 
kind  of  cavity.  The  mouth  is  more  or  less  open.  It  is  more 
so  in  recent  luxations,  than  in  those  that  have  continued  for 
some  time.  An  empty  space  is  felt  before  the  ear,  where  the 
condyles  were  placed.  The  coronoid  process  forms  under  the 
cheek-bone  an  eminence  which  is  felt  through  the  cheek,  or  by 
introducing  the  finger  into  the  mouth.  The  cheeks  and  tem- 
ples are  flattened  by  the  lengthening  of  the  temporal,  masseter, 
and  buccinator  muscles;  the  saliva  flows  in  large  quantities 
from  the  mouth,  irritated  by  constant  exposure  to  the  air, 
which  increases  its  secretions.  The  compression  made  on  the 
salivary  glands,  and  the  irritation  and  friftion  they  experience, 
contribute  to  render  the  secretion  of  the  saliva  still  more  abun- 
dant. The  arch  formed  by  the  teeth  of  the  lower  jaw  is  placed 
anterior  to  that  formed  by  those  of  the  upper,  and  the  direftion 

*  The  Physical  Journal'of  the  Abbe  Rozier  cortains  many  Memoirs  of 
Ci'izen  Pincl's  en  the  same  suhje6t ;  we  should  have  most  willingly  trans- 
ferred the  results  of  them  to  this  work,  did  it  not  require  a  greater  share 
of  the  knowledge  (f  geometry  to  understand  them,  tlvan  is  jpossessed  by 
the  generality  of  readers. 


OF    LUXATIONS    OF    tHE    LOWER    JAW.  223 

of  their  edges  shews  that  this  disposition  is  unnatural.  Lastly, 
the  patient  can  neither  speak  nor  swallow  during  the  first  days 
of  the  luxation. 

The  symptoms  just  pointed  out,  and  which  are  sufficient  to 
enable  us  to  establish  a  clear  diagnosis  when  the  luxation  is 
recent,  are  far  from  being  so  well  marked  when  the  disease  has 
continued  several  days  or  weeks.  In  these  cases  the  jaw  is  ele- 
vated insensibly,  and  approaches  the  maxilla  superior;  the  pa- 
tient recovers  by  degrees  the  faculty  of  speech  and  deglutition, 
but  he  still  stammers,  and  the  saliva  drivels  from  his  mouth. 
A  luxation  of  the  jaw  is  far  then  from  presenting  circum- 
stances from  which  we  are  to  form  so  unfavourable  a  prog- 
nosis as  that  made  by  Hippocrates,  who  says  that  it  is  fatal, 
unless  reduced  before  the  tenth  day.  Perhaps  trismus,  or  lock- 
jaw, "which  is  much  more  dangerous  than  luxation,  has  been 
confounded  with  it.  The  extreme  facility  with  which  these 
luxations  take  place  in  some  persons,  does  not  render  the  prog- 
nosis more  unfavourable;  in  such  the  redu£lion  is  easily  effedted, 
and  often  there  is  no  necessity  for  having  recourse  to  profes- 
sional men  to  accomplish  it.  Lastly,  the  operation  of  reduct- 
ion is  in  all  cases  simple,  and  certainly  successful  when  it  is 
done  after  the  following  manner: 

The  patient  is  to  be  seated  on  a  low  stool,  with  his  head 
supported  against  the  breast  of  an  assistant,  who,  by  placing 
his  hands  across  the  forehead,  is  to  fix  the  head.  In  this  po- 
sition of  the  patient,  the  surgeon's  hands  are  on  a  level  with 
the  mouth;  which  is  advantageous,  because  he  is  not  obliged 
to  elevate  them,  and  consequently  can  act  with  greater  force 
on  the  jaw.  The  surgeon,  after  securing  his  thumbs  with 
linen,  to  prevent  being  pained  by  the  compression  he  makes  on 
the  teeth,  introduces  them  into  the  mouth,  and  places  them  as 
far  back  as  possible  on  the  great  molares,  at  the  same  time 
bending  under  the  chin  the  four  fingers  of  each  hand.  If  there 
is  not  room  for  all  the  fingers  he  uses,  at  least,  the  index  and 
middle  finger.  Having  thus  seized  the  jaw,  he  presses  with 
his  thumbs  on  the  grieat  molares,  brings  the  jaw  downwards 
&nd  backwards,  and  disengages  the  condyles  from  the  zygo- 
matic foss*  into  which  they  were  carried.  When  the  muscles 
obey  this  effort,  and  it  is  found  that  the  condyles  yield  to  it 
and  descend,  the  chin  is  to  be  elevated  by  the  fingers;  thus 
converting  the  bone  into  a  lever  of  the  first  kind.  In  elevating 
the  jaw,  it  is  to  be  pushed  backwards. 

When  the  extension  has  been  effei^ual,  that  is  to  say,  when 
the  muscles  are  elongated  by  the  effort  to  depress  the  bone, 


224  Of    LUXATIONS    0#    THE    LOWER    JAW. 

they  contract  spasmodically  the  moment  that  the  condyles  are 
disengaged  from  the  zygomatic  fossx,  and  bring  these  processes 
into  the  glenoid  cavities  so  rapidly  and  forcibly,  that  there 
would  be  danger  of  having  the  thumbs  much  bruised  by  the  sud- 
den approximation  of  the  teeth,  if  the  precaution  were  not 
used  of  quickly  dire£ling  them  outwards,  and  placing  them  be- 
tween the  cheek  and  the  jaws. 

When  the  luxation  is  reduced,  which  is  known  by  its  cha- 
ra£leristic  symptoms  disappearing,  and  especially  by  the  jaws 
coming  together  in  their  natural  manner,  a  relapse  is  prevented 
in  this  way:  the  chin-bandage  is  to  be  applied,  to  prevent  the 
motion  of  the  bone,  which  it  does  in  a  most  effectual  manner, 
as  it  resists  the  muscular  adlion  that  tends  to  produce  it  at  the 
point  the  fa:rthest  removed  from  the  centre  of  motion.  This 
bandage  is  not  to  be  removed  but  when  the  patient  takes  food. 
During  the  first  days,  the  aliments  should  be  liquid,  or  such  as 
require  no  mastication.  When  solid  food  can  be  used,  the  pa- 
tient should  be  careful  to  support  the  chin  with  his  hand  each 
time  that  he  v.-ishes  to  depress  it. 

We  have  m.entioned  in  the  preceding  chapter  the  manner  in 
which  Le  Cat  succeeded  in  reducing  a  luxation  of  the  jaw,  viz. 
by  fatiguing  the  muscles.  This  means  would  be  proper  in  a 
similar  case,  and  should  be  had  recourse  to. 

Let  us  mention  here,  in  order  to  censure  it,  the  praflice  of 
reducing  luxations  of  the  jaw,  by  giving  a  blow  of  the  fist  to 
the  Under  part  of  the  chin.  Some,  however,  say,  that  this 
defeclive  mode  has  sometimes  succeeded;  but  it  is  easily  per- 
ceived that  the  blow  given  from  below  upwards,  tends  to  force 
the  condyles  deeper  and  deeper  into  the  zygomatic  fossae,  and 
that,  given  from  before  backwards,  it  may  fradlure  thes6  pro- 
cesses. 

The  ancients  placed  two  pieces  of  stick  between  the  great 
molares,  and  a£ling  with  them  as  levers  to  depress  the  lower 
jaw,  they  elevated  the  chin  by  means  of  a  bandage,  the  ends  of 
which  met  on  the  top  of  the  head.  This  process,  described 
with  much  perspicuity  by  Devigo,  is  extremely  methodical;  it 
is  not,  however,  preferable  to  that  of  the  moderns,  which, 
more  simple  than  it,  has  still  the  advantage  of  not  exposing  the 
teeth  to  be  broken  by  the  sticks,  at  the  moment  when  the  con- 
dyles re-enter  their  cavities. 

In  luxations  which  have  been  called  incomplete,  that  is  to 
sav,  when  only  one  condyle  has  escaped  from  its  cavity,  the 
treatment  requires  so  little  modification,  that  I  do  not  think  It 
necessary  to  enter  Into  further  details  on  this  subje(5l. 


?25 


CHAPTER  VI. 


OF  LUXATIONS  OF  THE  VERTEBRA. 

THE  large  surfaces  by  which  these  bones  correspond,  th© 
number  and  thickness  of  their  ligaments,  the  strength 
of  the  muscles  lying  on  the  column  formed  by  them,  the  small 
motion  of  which  each  vertebra  is  capable,  and  lastly,  the  ver- 
tical direction  of  their  articulating  apophyses,  render  a  luxation 
of  them  in  the  dorsal  and  lumbar  part  of  the  column,  entirely 
impossible.  A  violence,  though  ever  so  considerable,  cannot 
displace  them  without  first  fracturing  them.  The  same  is  not 
the  case  with  the  cervical  vertebrae;  the  extent  of  their  articu- 
lating surfaces  is  less,  the  ligamento-cartilaginous  substance 
which  unites  their  bodies  has  more  pliability,  the  motion  of  their 
articulations  is  greater,  and  their  articulating  surfaces  have  an 
oblique  direction,  which  allows  them  to  have  an  obscure  rota- 
tory motion;  consequently  luxations  of  them  are  sometimes 
met  with.  I  have  seen  a  case  in  which  the  neck  was  luxated 
by  a  violent  rotatory  motion  of  the  cervical  vertebrae,  and  the 
luxation  resisted  all  means  that  were  employed  to  reduce  it. 
The  cause  of  impediment  was  felt  towards  the  middle  of  the 
column  formed  by  the  cervical  vertebrae;  from  which  circum- 
stance we  may  conclude  that  the  dislocation  did  not  consist  of 
a  separation  of  the  first  vertebrae  from  the  second,  which  is 
admitted  to  be  possible  by  all  authors,  but  that  it  took  place 
lower  down  in  the  cervical  part  of  the  column. 

It  appears  from  well-attested  fa£ls,  that  luxations  may  take 
place  in  the  vertebral  column;  such  as  those  of  the  head  from 
the  first  vertebra,  and  of  the  first  vertebra  from  the  second. 
These,  and  especially  the  latter,  are  the  most  frequent;  but 
others,  though  much  rarer  and  more  diflicult,  may  however 
take  place. 


29 


226  OF    LUXATIONS    OF    THE    FIRST 


SECTION   I. 


Of  Luxations  of  the  Head  from  the  first  Vertebra. 

The  articulation  of  the  occipital  bone  with  the  first  vertebra 
of  the  neck  is  strengthened  by  means  of  many  ligaments,  and 
admits  of  only  very  limited  motions.  It  is  well  known,  that 
the  motions  of  inclination  of  the  head  to  the  right  and  left,  and 
of  flexion  and  extension,  take  place  along  the  whole  length  of 
the  cervical  vertebrae.  We  have  no  instance  of  luxation  of  the 
head  from  the  first  vertebra  by  an  external  cause;  such  a  dislo- 
cation, if  possible,  would  instantly  destroy  the  individual  to 
whom  it  happened,  by  the  compression  and  disorganization  of 
the  spinal  marrow.  But  nature,  which  cannot  bear  so  sudden 
a  change,  is  habituated  to  it  when  it  takes  place  gradually  and 
insensibly;  and  the  spinal  marrow,  which  a  sudden  though  in- 
considerable derangement  of  the  spine  would  totally  disorganize, 
is  not  sensibly  injured  when  it  takes  place  by  degrees;  cases  of 
rachitis  furnish  us  many  proofs,  of  this.  It  is  only  in  this  way 
that  we  can  explain  how  the  individual  from  whom  the  prepa- 
ration in  the  Museum  of  Natural  History  was  taken,  could  ex- 
ist until  such  very  great  deformity  took  place  in  his  spine. 


SECTION    II. 


Of  Luxations  of  the  first  cervical  Vertebra  from  the  second. 

It  is  principally  in  the  triple  articulation  of  these  two  verte-p 
brae,  that  the  motion  of  rotation  of  the  head  to  the  right  or  left 
takes  place;  for  the  union  of  the  first  vertebra  to  the  occipital 
bone  is  so  close,  that  the  motion  of  both  is  the  same.  This 
rotation  of  the  first  vertebra  on  the  second,  which  the  laxity 
and  weakness  of  the  ligaments  that  go  from  one  to  the  other, 
and  the  direftion  of  their  articulating  apophyses,  render  easy, 
would  be  frequently  carried  beyond  its  natural  bounds;  and 
luxation  would  take  place  every  time  we  turn  our  head  with 
force,  if  the  motion  were  not  confined  by  two  very  thick  liga- 


CERVICAL    VERTEBRA    FROM    THE    SECOND.       227 

ments,  which  go  from  the  sides  and  summit  of  the  toothlike 
process  of  the  second  vertebra  to  the  edges  of  the  great  occipital 
hole.  When  this  motion  is  forced  beyond  its  proper  limits, 
the  ligaments  are  torn,  and  the  lateral  parts  of  the  body  of  the 
first  vertebra  glide  along  on  the  articulating  horizontal  pro- 
cesses of  the  second  If  the  head  is  turned  from  the  left  to  the 
right,  the  left  side  of  the  body  of  the  vertebra  is  carried  before 
its  corresponding  articulating  surface,  whilst  the  right  side  falls 
behind  its  corresponding  surface.  In  this  luxation,  sometimes 
the  toothlike  process,  the  ligaments  of  which  are  broken,  leaves 
the  ring  formed  for  it  by  the  transverse  ligament  and  the  an- 
terior arch  of  the  first  vertebra,  and  presses  on  the  spinal  mar- 
row, the  substance  of  which  it  destroys;  at  other  times  it  re- 
mains on  its  ring,  but  the  diameter  of  the  vertebral  canal  is 
always  diminished  at  this  place,  and  the  spinal  marrow  expe- 
riences a  compression,  and  at  the  same  time  a  contortion,  by 
which  it  is  lacerated  It  is  easily  conceived  that  the  patient 
cannot  survive  a  derangement  of  this  nature;  every  lesion  of 
the  spinal  marrow  at  this  height  is  quickly  fatal.  Louis,  in 
making  researches  on  the  manner  of  dying  of  hanged  persons, 
found  that  those  despatched  by  the  executioner  of  Lyons,  pe- 
rished by  the  luxation  of  the  first  vertebra  from  the  second  j 
whilst  those  hanged  at  Paris  were  suffocated  by  strangulation. 
He  discovered  the  cause  of  this  difference  in  a  rotatory  motion 
given  to  the  body  of  the  culprit  by  the  executioner  of  Lyons,  at 
the  moment  that  the  ladder  was  taken  from  under  his  feet. 
We  ought  to  attend  to  this  observation,  when  we  examine  in 
a  judicial  capacity  the  body  of  a  person  found  hanged.  We 
should  carefully  examine  the  second  vertebra,  and  see  if  it  be 
luxated.  If  so,  the  individual  has  not  been  guilty  of  suicide, 
for  the  luxation  must  have  resulted  from  a  violent  motion  com- 
municated to  the  body  by  the  assassins. 

The  following  case  given  by  J.  L.  Petit,  furnishes  an  instance 
of  luxation  produced  by  the  motion  occasioned  by  the  person 
himself;  the  circumstances  of  it  are  so  extraordinary,  that  we 
shall  relate  them  at  full  length. 

"  The  only  son  of  a  tradesman,  aged  between  six  and  seven 
«<  years,  went  into  a  neighbouring  shop,  the  proprietor  of  which 
«  was  a  friend  of  his  father's.  This  person  playing  with  the 
«  child,  put  one  hand  under  his  chin  and  the  other  on  the  back 
"  of  his  head,  and  then  raised  him  up  in  the  air,  telling  him 
<'  that  he  was  gomg  to  shew  him  his  grandfather,  a  common 
«  expression  among  the  vulgar.  ^  Scarcely  was  the  child  raised 


228  OF    LUXATIONS    OF    THE    FIRST 

«  from  the  ground,  when  he  began  to  struggle,  and  by  his 
«*  efforts  dislocated  his  neck,  and  died  on  the  spojt.  The  father, 
"  on  hearing  of  the  death  of  his  child,  ran  in  a  fit  of  passion 
"  after  his  neighbour,  who  fled  before  him,  but  not  being  able 
«  to  catch  him,  he  threw  at  him  a  sadler's  hammer  which  he 
«  had  in  his  hand,  and  buried  the  cutting  part  of  it  in  the  de- 
"  pression  of  his  neck.  The  weapon  cut  all  the  muscles,  pe- 
"  netrated  into  the  space  between  the  first  and  second  cervical 
<t  vertebra,  divided  the  spinal  marrow,  and  occasioned  almost 
**  instantaneous  death.  Thus  both  perished  nearly  in  a  similar 
*'  manner."  J.  L.  Petit,  who  quotes  no  authority  to  support 
this  fact,  avails  himself  of  the  opportunity  of  censuring  this 
dangerous  sort  of  play,  and  observes  with  justice,  that  the  mo- 
tion which  the  child  gave  himself  was  the  cause  of  his  death. 

The  relaxation  of  the  ligaments  of  the  toothlike  process  may 
favour  this  luxation.  Such  probably  was  the  case  of  a  young 
man,  who  found  a  difiiculty  to  bring  his  head  back  to  its  natural 
posture,  each  time  that  he  turned  it  to  the  right  or  left.  There 
are  many  cases  of  luxation  of  the  neck,  in  which  death  does 
not  succeed  the  accident;  but  in  these,  the  dislocation  takes 
place  in  the  third,  fourth,  fifth,  or  sixth  vertebrae,  and  only 
one  articulating  process  is  luxated:  in  these  cases,  the  diameter 
of  the  vertebral  canal  is  not  so  much  diminished  as  to  compress 
the  spinal  marrow,  and  destroy  life;  but  a  wry-neck  remains, 
which  becomes  incurable,  unless  the  real  cause  of  it  be  found 
out. 

A  child,  whilst  playing  on  his  mother's  bed,  suddenly  felt 
pain  in  his  neck,  accompanied  with  a  distortion,  which  he  could 
not  remove.  Desault,  to  whom  the  child  was  brought,  disco- 
vered a  luxation  of  the  vertebrx  of  the  neck;  but  before  trying 
to  reduce  it,  he  informed  the  mother  that  the  child  might  die 
in  the  attempt.  This  information  terrified  the  mother  so  much, 
that  she  took  away  her  child  without  having  any  thing  done  to 
relieve  it. 

A  lawyer  writing  at  his  desk,  heard  the  door  behind  him 
open;  he  quickly  turned  round  his  head  to  see  who  was  co- 
ming in,  but  could  not  bring  it  back  again  to  its  natural  direft- 
ion.  Many  surgeons  of  Paris  have  seen  this  patient:  his  head 
was  turned  to  the  right,  and  slightly  inclined  to  the  shoulder 
of  the  same  side  This  inclination  was  much  less  than  it  would 
have  been  in  a  spasmodic  contradlion  of  the  sterno-cleido-mas- 
toideus  muscle. 


-Cervical  vertebra  from  the  second.     229 

Thus,  when,  in  consequence  of  a  sudden  and  violent  effort, 
the  head  is  found  turned  to  one  side,  either  right  or  left,  with 
inability  to  bring  it  back,  the  ear  a  little  inclined  to  one  side, 
and  the  sterno-cleido-mastoideus  in  a  state  of  relaxation,  there 
can  be  no  doubt  but  that  a  luxation  of  one  of  the  cervical  ver- 
tebrae has  taken  place. 

If  the  luxation  produce  no  symptom  which  indicates  a  com- 
pression of  the  spinal  marrow,  it  is  prudent  to  abstain  from  all 
attempts  to  reduce  it.  However,  if  the  patient  absolutely  insist 
on  our  interfering,  we  are  to  proceed  in  this  way:  we  begin  by 
inclining  the  head  to  the  side  towards  which  it  is  dire£led,  in 
order  to  disengage  the  articulating  process  of  the  upper  verte- 
brje:  this  part  of  the  operation  is  extremely  dangerous,  as  it 
may  kill  the  patient  by  causing  a  compression  on  the  spinal  mar- 
row. When  the  process  is  disengaged,  the  head  and  neck  are 
brought  to  their  right  direction,  by  making  them  perform  a  ro- 
tatory motion  the  contrary  of  that  which  had  taken  place  in  the 
luxation.  A  relapse  is  prevented  by  keeping  the  head  free  from 
motion.  This  is  done  by  means  of  bandages,  which  are  at- 
tached to  the  head  and  shoulders. 


23C 


CHAPTER  VII. 


OF  LUXATIONS  OF  THE  BONES  OF  THE  PELyiS. 


NONE  of  the  assemblage  of  bones  which  form  the  pelvis, 
are  susceptible  of  a  true  luxation.  It  is  impossible  that 
the  OS  sacrum,  inclosed  between  the  two  ossa  innominata,  can 
abandon  the  position  in  which  it  is  confined  by  such  powerful 
means.  The  os  coccygis,  which  has  more  motion,  is  easier 
fractured  than  luxated.  Citizen  Boyer  has  however  observed  a 
derangement  of  it,  in  a  man  greatly  emaciated  in  consequence 
of  long  disease:  he  had  considerable  ulcerations  in  the  neigh- 
bourhood of  the  coccyx,  and  the  bone  itself  was  laid  bare  by 
the  separation  of  a  large  gangrenous  eschar.  There  was  an 
interval  of  nearly  two  inches  between  the  summit  of  the  sacrum 
and  the  base  of  the  os  coccygis.  But  in  proportion  as  he  re- 
covered strength,  the  bone  was  drawn  backwards,  and  was  at 
last  united  to  the  sacrum,  notwithstanding  the  aflion  of  the 
levatores  ani  which  are  attached  to  it.  The  ossa  innominata 
are  too  firmly  articulated  with  one  another,  and  with  the  sa- 
crum, to  admit  of  luxation;  however,  the  symphysis  pubis  and 
sacro-iliac  synchondrosis,  which  in  the  natural  state  admit  of 
no  motion,  may  be  so  relaxed,  or  the  ligamento-cartilaginous 
substance  which  unites  them  may  be  so  far  destroyed,  and  the 
bones  thereby  rendered  so  moveable,  that  progression,  which 
requires  the  firm  union  of  these  bones,  becomes  difiicult.  Is 
this  relaxation  of  the  articulations,  and  the  consequent  seceding 
of  the  bones,  a  means  employed  by  nature  to  increase  the  dia- 
meters of  the  pelvis,  and  facilitate  parturition  ?  Louis  has  shewn, 
in  a  dissertation,  which  is  found  in  the  first  part  of  the  fourth 
volume  of  the  Memoirs  of  the  Academy  of  Surgery,  how  many 
different  opinions  authors  have  on  this  subjeft.  Some,  in  re- 
ality, suppose  that  the  relaxation  of  the  articulations  is  the  na- 
tural state  towards  the  end  of  pregnancy;  others  consider  it  as 
being  always  morbid.     Were  we  permitted  to  give  an  opinion 


OF    LUXATIONS    OF    THE    PELVIS.  23 1 

on  this  subjeft,  which  comes  chiefly  under  the  cognizance  of 
accoucheurs,  we  would  say,  that  the  symphysis  pubis  and  the 
sacro-iHac  synchondrosis  abound  with  juices,  and  are  swelled 
and  relaxed  in  a  remarkable  manner,  in  most  women  during 
pregnancy,  that  this  relaxation  seldom  goes  so  far  as  to  allow 
the  bones  to  move  and  be  separated;  and  lastly,  that  the  mo- 
tion or  separation  of  the  bones  is  to  be  considered  rather  as  a 
morbid  than  natural  state. 

A  lady  was  suddenly  delivered  of  a  child,  without  almost  any 
pain:  but  the  ovum  came  away  entire,  and  with  such  rapidity, 
that  the  women  in  the  chamber  could  scarcely  reach  her  in 
time  to  receive  it.  No  bad  symptom  supervened  until  the 
fourth  day:  at  this  time  a  fever  appeared,  and  the  patient  died 
on  the  seventh  day.  Citizen  Boyer,  on  opening  the  body,  per- 
ceived that  the  ossa  pubis  were  moveable,  and  remarked  this 
circumstance  to  Citizen  Baudelocque.  Curious  to  discover  the 
cause  of  it,  they  divided  the  symphysis  pubis,  and  found  a  great 
vacuum  in  the  centre  of  it,  round  which  the  relaxed  ligamento- 
cartilaginous  substance  formed  a  raised  margin,  which  was  made 
to  puff  up  by  the  approximation  of  the  ossa  pubis.  In  every 
other  particular  the  pelvis  was  well  formed,  and  the  woman 
had  had  many  easy  deliveries. 

When  a  woman,  towards  the  end  of  pregnancy,  after  partu- 
rition, or  during  any  other  time,  feels  pain  in  the  articulations 
of  the  pelvis,  and  the  mobility  of  the  bones  renders  progression 
difficult  and  tottering,  she  should  be  confined  to  her  bed,  the 
pelvis  should  be  surrounded  with  bandages  drawn  very  tight, 
and  the  region  of  the  pubis  should  be  covered  with  astringent 
applications  J  but  as  these  latter  aft  only  on  the  external  surface, 
we  are  to  expedt  much  less  from  them  than  from  corroborants 
administered  internally,  and  the  use  of  bandages. 

The  treatment  suited  to  a  relaxation  of  the  symphysis  pubis 
is  also  adapted  to  that  of  the  sacro-iliac  synchondrosis.  We  do 
not  beheve  that  a  sudden  and  violent  separation  of  the  thighs 
can  produce  a  disjointing  of  the  latter,  though  a  case  of  this 
kind  is  given  in  the  Anatomico-surgical  Observations  of  Blasius. 
It  is  probable  that  the  motion  of  the  bones  in  this  case  took 
place  from  the  laxity  of  the  ligaments;  and  thiff  seems  to  be 
proved  by  the  history  of  the  patient,  who  was  a  young  student 
in  law,  and,  as  Blasius  expresses  it,  of  an  effeminate  constitu- 
tion and  a  relaxed  and  delicate  habit. 

But  that  which  a  sudden  and  violent  separation  of  the  thighs 
cannot  produce  may  be  occasioned  by  external  violence.  Louis's 
Dissertation,  cited  above,  is  terminated  by  the  following  case: 


232  OF    LUXATIONS    OF    THE 

A  sack  of  wheat,  of  three  hundred  and  fifty  pounds  weight,^ 
fell  on  the  back  of  a  labourer  who  was  unloading  a  waggon. 
The  posterior  part  of  the  pelvis,  on  which  the  weight  fell,  was 
very  much  shaken;  however,  the  pain  was  so  inconsiderable, 
that  it  was  only  after  some  days  that  the  patient  sought  relief. 
The  bad  symptoms  now  increased  rapidly,  and  he  died  on  the 
twentieth  day.  On  opening  the  body,  the  os  ilium  of  the  right 
side  was  found  separated  from  the  sacrum,  passing  nearly  three 
inches  behind  it;  the  parts  contained  in  the  pelvis  were  in- 
flamed, there  was  an  effusion  of  purulent  matter  into  the  lower 
region  of  the  abdomen,  and  the  luxated  bones  moved  freely  on 
one  another. 

The  possibility  of  a  luxation  of  the  sacro-iliae  synchondrosis 
by  external  violence  is  then  proved  beyond  all  doubt ^  but  it 
must  be  very  rare;  and  in  the  particular  case  just  related,  no- 
thing less  than  a  very  great  weight  favoured  by  the  position  of 
the  pelvis  could  have  caused  it.  An  antiphlogistic  treatment  is 
particularly  adapted  to  such  cases;  for  the  danger  depends  on 
the  inflammation  which  must  necessarily  follow  such  considera- 
ble external  violence,  and  which,  if  it  extend  to  the  organs 
contained  in  the  cavity  of  the  pelvis,  may  produce  the  worst 
Gonsequences.  The  accession  of  inflammation  should,  if  pos- 
sible, be  prevented;  if  not,  it  becomes  quickly  fatal,  unless  it 
is  arrested  in  its  progress  by  copious  and  repeated  bleedings,  the 
use  of  warm  baths,  emollient  fomentations,  and  the  most  rigid 
abstinence. 

As  to  the  supposed  luxations  of  the  ribs  admitted  by  some 
authors,  we  should  have  observed,  respedling  them,  the  same 
silence  as  J.  L.  Petit,  did  not  a  case  inserted  in  the  Memoirs  of 
the  Academy  of  Surgery,  after  the  death  of  that  celebrated  prac- 
titioner, seem  to  establish  the  possibility  of  their  taking  place.  It 
is  not,  however,  difficult  to  perceive,  in  reading  this  case,  that  the 
surgeon  who  has  given  it  has  committed  a  strange  mistake,  by 
taking  a  simple  fradture  of  the  posterior  extremity  of  these  bones 
for  a  luxation  of  them.  If  we  attend  to  the  nymber  and  force  of 
the  ligaments  which  attach  the  ribs  to  the  vertebrae  and  ster- 
num, and  also  to  the  manner  in  which  the  intercostal  and  other 
muscles  confine  them,  we  shall  not  easily  conceive  how  external 
violence,  whether  it  acts  on  their  middle  or  extremities,  can 
luxate  them.  They  are  so  firmly  attached  to  the  surrounding 
parts,  that  it  is  very  difficult  to  separate  them  from  the  body 
in  the  dead  subjeft;  and  in  preparing  skeletons,  we  often  break 
them  if  we  are  not  careful  to  cut  all  their  bonds  of  union  be- 


Cones  of  the  pelvis.  233 

fore  we  attempt  to  detach  them  from  the  parts  with  which  they 
are  articulated.  All  the  symptoms  presented  by  the  case  of  the 
patient  of  Buttet,  surgeon  of  Etampes,  indicate  a  fracture  of 
the  neck  or  posterior  extremity  of  the  rib;  the  pain,  crepita- 
tion, and  motion  of  the  bone,  are  characteristic  marks  of  it. 
The  author  proves  nothing  by  saying,  that  the  noise  arising 
from  the  motion  of  the  rib  was  very  distinft,  and  heard  by  him- 
self and  his  assistants,  whilst  that  which  charadterizes  fraftures 
is  only  sensible  to  the  hands,  and  that  the  rib  could  be  moved 
in  its  whole  length.  First,  it  cannot  be  conceived  how  the 
noise  which  accompanies  the  motion  of  fra<Slured  bones  can  be 
sensible  to  the  organ  of  touch.  Next,  the  fra(Slure  having  taken 
place  very  near  the  posterior  extremity  of  the  rib,  rendered  it 
impossible  to  draw  any  conclusion  from  its  motion,  as  in  this 
case  it  would  have  the  appearance  of  moving  entirely  along  its 
length;  besides,  it  is  very  difficult  to  feel  this  motion  through 
the  muscles  of  the  spine.  Thus  we  regard  luxations  of  the 
ribs  as  totally  impossible,  though  Ambrose  Pare,  and  after  him 
Barbette,  Junker,  Platner,  and  Heister,  admit  them,  and  give 
different  species  of  them. 

We  must  not,  with  Lieutaud,  give  this  name  to  afFe6tIons 
in  which  the  body  of  the  dorsal  vertebrae  and  the  head  of  the 
rib  are  separated  from  one  another  by  a  caries  of  these  parts. 

It  might  happen,  that  by  a  violent  and  sudden  contraction 
of  the  pedtoralis  major,  the  cartilage  of  the  sixth  true  rib,  to 
the  whole  extent  of  which  this  muscle  is  attached,  might  be 
separated  from  that  of  the  seventh;  and  that  the  very  thin  cap- 
sule which  keeps  them  together  might  be  torn.  The  pain 
alone  would  point  out  this  affection.  With  respedt  to  the 
depression  of  the  other  cartilages,  and  of  the  appendix  xypho- 
ides,  we  refer  to  what  we  have  said  on  that  subje£t  in  treating 
of  fractures  of  these  parts* 


50 


^34 


CHAPTER  VIII. 


OF  LUXATIONS  OF  THE  CLAVICLE. 

LUXATIONS  are  in  general  much  less  frequently  met 
with  than  fractures.  How  numerous  are  fractures  of  the 
body  and  neck  of  the  femur  compared  to  luxations  of  this  bone ! 
A  surgeon,  who  has  seen  hundreds  of  the  former,  generally 
meets  in  the  course  of  a  long  and  extensive  praftice  only  a  very 
few  cases  of  primary  luxations  ©f  the  thigh.  These  general 
considerations  apply,  in  a  certain  degree,  to  the  bone,  the  lux- 
ations of  which  form  the  subject  of  this  chapter.  We  find,  in 
fact,  that  fractures  of  the  clavicle  are  much  more  frequent  than 
luxations  of  it,  and  it  has  been  supposed  that  they  bear  a  pro- 
portion to  one  another  of  6  to  1 .  These  luxations  are  distin- 
guished into  that  of  the  extremity  next  the  sternum,  and  that 
of  the  extremity  next  the  humerus. 


SECTION    I. 


Of  Ltmations  of  the  Extremity  next  the  Sternum. 

This  extremity  presents  a  large  surface,  which  is  articulated 
with  another  much  smaller  in  the  lateral  and  superior  part  of 
the  sternum.  This  disproportion  in  the 'articulating  surfaces 
disposes  to  dislocations,  which  are  also  favoured  by  the  weak- 
ness of  the  ligaments,  and  the  motions  and  funftions  of  the 
Joint.  It  is,  in  faft,  in  this  articulation,  furnished  internally 
with  an  inter-articular  cartilaginous  lamina,  that  all  the  efforts 
made  by  the  superior  extremity  terminate. 

The  clavicle  may  be  luxated  at  this  extremity  forwards,  back- 
wards, and  upwards,  but  never  downwards:  the  cartilage  of 
the  first  rib  borders  its  extremity  on  this  side,  and  renders  a 


OF    LUXATIONS    OF    THE    CLAVICLE.  235 

luxation  of  it  in  this  direction  impossible.  Of  the  three  possi- 
ble kinds  of  luxation,  that  anteriorly  is  the  most  frequent,  and 
indeed  almost  the  only  one  met  with.  To  eff&6\  it,  it  is  only 
necessary  that  the  clavicle,  naturally  directed  backwards,  be 
carried  still  more  in  that  dire6Vion:  this  motion  of  the  shoul- 
der backwards  is  the  easiest  and  most  extensive  of  any  of  which 
this  part  is  capable.  Accordingly,  nature  has  diminished,  as. 
much  as  in  her  power,  the  tendency  to  dislocation  which  results 
from  it,  by  giving  great  force  to  the  anterior  ligament,  which 
is  still  strengthened  by  the  portion  of  the  sterno-cleido-mastoi- 
deus  attached  to  the  sternum.  Luxations  backwards  and  up- 
wards are  very  rare:  to  effeCt  the  former,  the  shoulder  must  have 
been  pushed  forwards  violently  and  to  a  considerable  distance, 
and  at  the  same  time  suddenly  depressed  by  a  great  force:  a 
combination  of  these  circumstances  sometimes  takes  place  in 
falls.  Lastly,  of  the  two  luxations  upwards  and  backwards, 
the   latter  is  that  most  rarely  met  with. 

If  the  shoulder  be  pushed  violently  backwards,  the  extremity 
of  the  clavicle  next  the  sternum  is  carried  forwards,  lacerates 
the  capsule  of  the  articulation,  the  anterior  ligament,  and  the 
tendon  of  the  sterno-cleido-mastoideus  muscle,  abandons  the 
surface  it  was  articulated  with,  and  passes  before  the  superior 
part  of  the  sternum-,  forming  under  the  skin,  the  only  covering 
at  this  place,  a  hard,  projecting,  circumscribed  tumour,  which 
follows  the  motions  of  the  shoulder.  The  force  which  causes 
the  luxation  will  a£l  with  the  greatest  advantage,  if  applied  to 
the  point  of  the  shoulder,  which  is  the  part  the  most  distant 
from  the  articulation  in  which  the  dislocation  takes  place.  A 
baker's  boy,  in  order  to  repose  himself,  rested  his  basket  full  of 
bread  on  the  parapet  of  a  bridge:  the  basket  lost  its  equilibrium, 
and  vv^as  falling  backwards;  the  boy  endeavoured  to  oppose  it, 
and  in  the  effort,  the  straps  which  passed  under  each  arm-pit 
afted  so  powerfully  on  the  point  of  his  shoulders,  that  one  of 
his  clavicles  was  luxated  forwards. 

When  the  shoulder  is  suddenly  depressed,  the  extremity  of 
the  clavicle  next  the  sternum  is  luxated^asily  upwards,  as  there 
is  nothing  to  limit  its  motion  in  this  dire<51;ion,  except  the  inter- 
clavicular ligament  •,  which,  however,  being  relaxed  by  the 
greater  contiguity  of  the  two  bones,  makes  only  a  very  feeble 
resistance. 

In  the  luxation  backwards,  the  extremity  of  the  clavicle  is 
carried  behind  the  superior  part  of  the  sternum;  but  in  this,  as 
in  the  two  preceding,  all  the  ligaments  that  surround  the  arti- 


S.^^  OF    LUXATIONS    OF    THE    CLAVICLE." 

culatlon  are  torn:  this  is  the  case,  even  with  the  costo-clavicular 
ligament,  which  does  not  immediately  belong  to  it.  This  la- 
ceration, with  the  pecuHarity  of  strudlure,  renders  the  treat- 
ment of  this  luxation  difficult. 

The  superficial  situation  of  the  clavicle  renders  a  diagnosis 
very  easy.  If  the  luxation  be  forwards,  a  hard  circumscribed 
tumour  is  felt,  or  even  seen,  on  the  anterior  and  superior  part 
of  the  sternum,  which  is  made  to  disappear  by  carrying  the 
shoulder  forwards  and  outwards;  and  an  empty  space  is  found 
where  the  head  of  the  clavicle  should  be  placed,  &c.  &c.  In 
luxation  upwards,  the  space  between  the  sternal  ends  of  the 
clavicles  is  diminished.  If  the  luxation  be  backwards,  there  is 
a  depression  at  the  place  where  the  extremity  of  the  clavicle 
should  be  placed,  and  a  tumour  is  formed  by  it  at  the  anterior 
and  inferior  part  of  the  neck,  which,  as  J.  L.  Petit  observes, 
may  compress  the  trachea  arteria,  oesophagus,  jugular  vein,  ca- 
rotid artery,  and  nerves;  lastly,  the  head  is  inclined  towards 
the  affe^ed  side.  By  attending  to  these  appearances,  and  to 
the  history  of  the  circumstances,  we  shall  be  able  to  ascertain 
the  existence  of  the  dislocation,  and  find  out  in  what  dire«Stion 
it  has  taken  place. 

A  luxation  of  this  extremity  of  the  clavicle  is  reduced  In  the 
same  way  as  a  fra6lure  of  this  bone;  that  is,  by  making  a  lever 
of  the  arm,  by  means  of  which  the  shoulder  is  brought  out- 
wards;'and  when  the  shoulder  is  brought  outwards  in  this 
manner  it  is  pushed  forwards,  if  the  luxation  has  taken  place 
in  that  diredlion;  backwards,  if  it  be  posteriorly;  and  we  elevate 
it  if  the  bone  Is  dislocated  upwards.  By  these  means  we  make 
extension,  disengage  the  extremity  of  the  bone,  and  bring  it 
towards  Its  corresponding  articulating  surface:  when  in  this 
state,  by  pressing  on  it  with  the  thumb,  it  Is  restored  to  its 
natural  situation;  but  it  Is  as  difficult  to  keep  It  In  its  place,  as 
it  is  easy  to  reduce  It.  All  the  ligaments  being  more  or  less 
lacerated,  the  articulating  surfaces,  which  are  smooth  and  dis- 
posed obliquely,  slide  easily  on  one  another  from  the  least  mo- 
tion of  the  shoulder. 

The  apparatus  used  In  fractures  of  the  clavicle  is  to  be  applied 
in  cases  of  luxations  of  the  extremity  next  the  sternum.  But 
it  must  be  observed,  that  this  apparatus,  which  makes  a  conti- 
nued extension  by  means  of  the  cushion  placed  in  the  axilla, 
though  ever  so  well  applied,  will  not  keep  the  clavicle  exactly 
in  its  place;  and  notwithstanding  the  greatest  assiduity  of  the 
surgeon,  the  luxated  extremity  will  remain  more  prominent 


OF    LUXATIONS    OF    THE    CLAVICLE.  237 

than  that  of  the  opposite  side.  This  slight  and  inevitable  de- 
formity would  not  be  prevented,  even  though  the  tourniquet 
proposed  by  Brasdor  to  make  pressure  on  the  extremity,  and 
thus  keep  it  reduced,  were  used.  It  will  be  necessary  to  con- 
tinue the  use  of  the  bandage  for  a  considerable  time,  in  order 
to  favour  the  union  of  the  lacerated  ligaments. 


SECTION   ir. 


Of  Luxations  of  the  Extremity  next  the  Humerus. 

These  luxations,  less  frequent  than  the  former,  take  place 
by  a  mutual  sliding  of  two  oblique  and  small  surfaces  on  one 
another,  which  form  the  articulation  of  the  humeral  extremity 
of  the  clavicle  with  the  acromion  of  the  scapula.  As  these  ar- 
ticulating surfaces  are  turned  upwards,  luxation  seldom  takes 
place  but  in  this  diredtionj  it  is  proved,  however,  that  it  may 
take  place  downwards,  and  that  the  extremity  of  the  clavicle 
may  sHde  and  pass  under  the  acromion.  The  very  great  force 
of  the  conoid  and  trapezoid  ligaments  which  unite  the  clavicle 
to  the  scapula,  renders  luxations  of  the  humeral  extremity  very 
rare.  The  dislocation  upwards,  the  only  one  that  merits  par- 
ticular consideration,  may  be  occasioned  by  a  fall  on  the  summit 
of  the  shoulderj  in  which  case,  the  humeral  extremity  of  the 
clavicle  slides  upwards  on  the  facet  of  the  acromion,  and  mounts 
on  this  process,  which  is  itself  caried  a  little  under  the  displaced 
bene,  when  the  shoulder  is  drawn  inwards  by  the  aftion  of 
the  muscles  which  bring  the  arm  near  the  body.  In  this  lux- 
ation, the  capsule,  the  superior  ligament  of  the  articulation,  as 
also  the  aponeurotic  expansion  of  the  trapezius  and  deltoid 
muscles,  and  the  conoid  and  trapezoid  ligiments,  are  ruptured. 

This  luxation,  which  is  always  occasioned  by 'falling  on  the 
shoulder,  may  be  said  so  be  produced  by  the  violence  of  the  fall 
and  the  a6tion  of  the  trapezius  muscle.  This  muscle,  the  fi- 
bres of  v/hich  arc  attached  to  the  external  half  of  the  clavicle, 
contrafts,  and  tends  to  elevate  the  shoulder,  and  bring  it  back- 
wards; but  as  the  shoulder  is  forced  against  the  ground,  and 
cannot  obey  this  a6lion,  the  conoid  and  trapezoid  ligaments  are 
torn,  and  the  humeral  extremity  of  the  clavicle  displaced.  This 
explanation  will  not  appear  improbable  to  those  who  know 


SjS  OF    LUXATIONS    OF    THE    CLAVICLE. 

what  prodigious  force  muscles,  in  appearance  the  weakest,  ex- 
ert, and  what  enormous  resistance  they  sometimes  surmount. 

The  existence  of  this  luxation  is  easily  assertained.  If  there 
be  pain  in  the  top  of  the  shoulder  succeeding  to  a  fall  on  that 
part;  and  if,  on  examination,  the  extremity  of  the  clavicle  be 
found  projefting  under  the  skin  covering  the  acromion,  we 
may  be  sure  it  has  taken  place.  Besides,  the  patient  inclines 
his  head  to  the  affedled  side,  and  moves  as  little  as  possible  ei- 
ther the  arm  or  shoulder,  because  he  cannot  move  these  parts 
without  calling  into  adlion  the  deltoid  or  some  other  muscle, 
which  would  consequently  extend  the  motion  to  the  diseased 
part,  and  cause  pain.  This  luxation  is  not  attended  with  such 
dangerous  consequences  as  those  related  by  Ambrose  Pare.  He 
says,*  the  bone  cannot  be  reduced,  the  patient  will  remain  dis- 
abled, and  will  never  be  able  to  carry  his  hand  to  his  mouth  or 
head.  In  fadl,  the  clavicle  has  been  often  but  imperfeftly  re- 
duced, and  the  patients  were  not  disabled;  and  this  is  what  is 
observed  even  in  the  greater  number  of  cases:  the  ligaments 
heal  without  uniting,  and  the  luxation  relapses  as  soon  as  the 
bandage  is  removed.  I  have  seen  a  person  who  had  a  luxation 
of  this  kind,  and  who,  after  five  months  regular  treatment, 
could  not  move  his  arm  without  dislocating  the  clavicle;  when- 
ever he  used  his  arm,  the  scapula  was  carried  backwards,  and 
its  base  raised  up  the  skin. 

We  reduce  this  luxation  by  carrying  the  arm  outwards,  by 
putting  a  cushion  in  the  axilla,  and  applying  Desault's  bandage 
for  fractures  of  the  clavicle,  in  such  a  manner  as  that  all  the 
turns  of  it  which  ascend  from  the  elbow  to  the  shoulder  may 
bear  on  the  luxated  extremity,  compress  it,  and  keep  it  in  its 
place. 


*  Works  of  AmbroEe  Pare,  chap.  il.  of  Luxations  of  the  Clavicle. 


239 


CHAPTER  IX. 


OF  LUXATIONS  OF  THE  OS  HUMERI. 

THERE  is  no  articulation  which  admits  of  such  extensive 
motion,  as  that  of  the  humerus  with  the  scapula:  conse- 
quently, luxations  of  the  former  are  extremely  frequent:  their 
number  equals,  if  not  exceeds,  that  of  the  luxations  of  all  the 
other  bones.  The  head  of  the  humerus,  a  large  hemispherical 
body,  is  not,  properly  speaking,  entirely  received  in  the  gle- 
noid cavity  of  the  scapula,  which,  notwithstanding  the  fibrous 
margin  with  which  it  is  surrounded,  is  not  deep  enough  for 
this  purpose.  It  touches  this  cavity  by  only  a  very  few  pointsj 
the  greater  part  of  its  surface  is  in  contact  with  the  orbicular 
ligament.  The  articulation  itself,  though  admitting  of  great  lati- 
tude of  motion,  is  by  no  means  provided  with  very  strong  liga- 
ments; it  derives  its  principal  strength  from  the  orbicular  liga- 
ment, and  an  accessary  one  which  comes  from  the  coronoid 
process  of  the  scapula.  These  circumstances  render  dislocations 
of  the  arm  so  easy,  that,  were  it  not  for  the  great  mobility  of 
the  scapula,  which  follows  the  humerus  in  ail  its  motions,  the 
latter  would  be  dislocated  by  every  trifling  effort.  The  mobility, 
then,  of  the  articulating  surfaces  diminishes  the  frequ-oncy  of 
luxations,  which  are  favoured  by  so  many  circumstances. 

The  humerus  can  be  luxated  only  in  three  directions,  down- 
wards, inwards  or  forwards,  and  outwards  or  backwards.  Lux- 
ation upwards,  admitted  by  some  authors,  is  rendered  impossible 
by  many  causes:  first,  the  acromion  and  coracoid  process  form, 
with  the  triangular  ligament  which  goes  from  the  one  to  the 
other,  a  kind  of  vault  over  the  articulation;  therefore,  the  first 
effedt  of  every  effort  to  push  the  humerus  upwards,  would  tend 
to  frafture  these  two  processes,  and  tear  their  ligament;  and  as 
the  head  of  the  humerus  should  be  carried  at  once  upwards  and 
outwards,  before  it  could  be  luxated  in  this  direClion,  the  trunk 
prevents  this  disposition  of  the  parts  by  not  allowing  the  elbow 
to  be  brought  sujSiciently  inwards.     Lastly,  the  tendons  of  the 


240  OF    LUXATIONS    OF    THE    OS    HUMERI. 

biceps  and  supraspinatus,  and  the  fleshy  mass  of  the  deltoid 
muscle,  efficaciously  prevent  this  luxation.  There  is  even  one 
of  the  three  species  of  luxation  of  the  humerus,  of  which, 
though  it  has  been  described,  and  the  possibility  made  evident, 
we  are  not  acquainted  with  a  single  instance:  it  is  the  luxation 
outwards  or  backwards.  The  other  two  then  are  those  that 
merit  the  attention  of  pra(fi:itioners :  the  first  is  oftener  met 
with  than  the  second;  it  is  even  so  frequent,  that  many  authors, 
conformably  to  the  opinion  of  Hippocrates,  think  that  every 
primary  luxation  of  the  humerus  takes  place  downwards:  we 
say  primary  luxation ;  for  the  possibility  of  a  subsequent  change 
of  place,  by  which  the  head  of  the  luxated  humerus  is  carried 
fortvards,  is  generally  admitted.  In  order  to  explain  this  sub- 
sequent change  of  place,  let  us  suppose  the  head  of  the  hume- 
rus, in  a  luxation  downwards,  to  be  placed  between  the  tendon 
of  the  long  portion  of  the  triceps,  and  that  of  the  subscapularis; 
but  by  a  fall  or  muscular  adlion,  to  be  pushed  forwards  and 
inwards,  and  obliged  to  lodge  between  the  fossa  subscapularis 
and  the  muscle  of  that  name.  Luxation  downwards  can  never 
be  converted  into  that  backwards;  though  the  contrary  opinion 
is  supported  by  J.  L.  Petit;  but,  respectable  as  his  authority 
may  be,  we  easily  conceive  that  the  resistance  made  by  the 
tendon  of  the  long  portion  of  the  triceps  must  prevent  it. 

Luxation  of  the  humerus  downwards  is  the  most  frequent, 
not  only  on  account  of  the  great  extent  of  motion  of  the  bone 
necessary  to  produce  it,  but  also  because  the  lower  part  of  the 
orbicular  ligament  is  the  thinnest  and  weakest,  and  the  least 
supported.  The  tendons  of  the  supraspinatus,  teres  minor, 
and  subscapularis,  are  in  some  sort  confounded  with  the  orbi- 
cular ligament  before  they  are  inserted  into  the  tuberosities  of 
the  humerus,  and  thus  increase,  in  a  remarkable  manner,  its 
strength  and  thickness  on  the  superior  side;  the  tendons  of  the 
teres  minor  and  infraspinatus  support  the  head  of  the  bone  on 
the  outside;  above,  the  same  purpose  is  answered  by  the  ten- 
don of  the  supraspinatus,  and  that  of  the  long  portion  of  the 
biceps;  and  anteriorly  and  interiorly  it  is  protedled  by  the  ten- 
don of  the  subscapularis.  The  inferior  part  of  the  articulation 
is  deprived  of  a  similar  support,  and  corresponds  to  the  cellular 
substance,  the  glands,  nerves,  and  blood-vessels  that  fill  the 
axilla.  Now,  when  the  elbow  is  carried  upwards  and  outwards, 
the  head  of  the  humerus,  by  pressing  on  the  inferior  side  of 
the  obicular  ligament,  may  easily  lacerate  it;  but  in  the  mean 
time,  the  tendon  of  the  long  portion  of  the  triceps  opposes  its 


OP^  LUXATIONS    OF    THE    OS    HUMERI.  24I 

)?sfcape  precisely  at  the  inferior  part  of  the  cavity,  and  forces  it 
^o  pass  out  at  its  inferior  and  internal  part.  In  this  luxation  the 
head  of  the  humerus  is  found  placed  on  the  superior  and  inter- 
nal part  of  the  external  costa  of  the  scapula,  having  before  it 
the  anterior  edge  of  the  subscapularis,  and  the  tendon  of  the 
long  portion  of  the  triceps  behind  it.  The  laceration  of  the  cap- 
sular ligament  is  inseparable  from  this  luxation  j  it  could  not 
take  place  without  this  happening. 

In  order  that  this  dislocation  may  take  place,  the  elbow  must 
be  moved  outwards  from  the  body,*  and  even  a  little  elevated  : 
in  this  motion  of  the  arm,  the  head  of  the  humerus  slides  from 
above  downwards,  and  presses  on  the  internal  and  inferior  part 
of  the  orbicular  ligament.  The  difficulty  we  experience  in 
luxating  the  arm  downwards  in  the  dead  body,  is  so  great,  that 
we  may  conclude,  that  the  weight  of  the  body  alone  would  sel- 
dom luxate  it  in  falls  on  the  elbow,  were  it  not  for  the  co-ope- 
tation  of  muscular  action.  In  order  to  elucidate  the  manner  iri 
which  this  luxation  is  efFedled,  let  us  suppose  a  case  :  A  person 
falls  from  a  place  somewhat  elevated,  on  his  elbow  moved  otit 
from  the  body  ;  but,  on  the  very  moment  that  the  elbow  reach- 
es the  ground,  the  pectoralis  major,  teres  major  and  latissimus 
dorsi,  contract,  and  draw  the  arm  near  the  body  :  now,  the  con- 
sequence must .  be,  as  the  elbow  is  fixed  against  the  ground, 
that  the  muscles  will  bring  downwards  and  inwards  the  head 
of  the  humerus.  This  force,  co-operating  with  that  of  the  fall, 
forces  the  head  of  the  humerus  through  the  ligament,  and 
produces,  a  luxation  downwards.  The  humerus  represents 
here,  as  in  all  its  motions,  a  lever  of  the  third  kind  ;  but  its  re- 
lations are  changed,  the  force  remaining  alwaj^s  at  the  middle, 
the  pomt  d'appuiy  which  was  in  the  articulation  of  the  hume- 
rus, is  now  transferred  to  the  elbow. 

Some  authors  think,  that  when  the  arm  is  moved  out  from 
the  body,  the  adlion  of  the  deltoid  muscle  alone  can  produce  a 
dislocation  of  it ;  and  in  support  of  this  opinion  they  refer  to 
the  case  of  a  person  who  luxated  his  arm  in  attempting  to 
raise  a  registry-book. 

When  the  luxation  has  taken  place,  the  head  of  the  hume- 
rus, placed,  as  already  observed,  between  the  subscapularis 
jauscle  and  this  tendon  of  the  long  portion  of  the  triceps,  fills 

*  I  have  £,iven  in  the  Journal  de  MeJecirie,  the  liisfoiy  of  a  luxatiuu 
produced  by  a  fall  on  the  topcf  tlic  bhoulder ;  but  we  inaye.isily  conceive 
ihat  such  ca.'^es  nuist  be  ex'remely  rare,  and  that  fracture  of  the  r.eck  cf 
the  hume;\!5  is  tj  be  expected  from  iucli  u  cauoc,  rather  than  luxauuu. 


242  or    LUXATIONS    OF    THE    OS    HUMERI. 

the  hollow  of  the  arm-pit ;  the  orbicular  ligament,  torn  on  its 
internal  side,  is  stretched  over,  and  covers  the  glenoid  cavity  •, 
fhe  deltoides  and  infraspinatus  muscles  are  elongated  on  account 
of  the  separation  of  their  points  of  insertion  ;  the  teres  minor 
and  subscapularis  areneither  stretched  nor  elongated,  for  if  their 
superior  fibres  experience  attention,  the  inferior  are  relaxed ; 
the  coracobrachialis,  the  biceps  and  triceps,  are  elongated,  and 
the  fore-arm  is  more  or  less  bent  •,  the  brachial  plexus  and  ax- 
illary vessels  are  not  injured ;  the  circumflex  nerve,  which 
furns  under  the  head  of  the  humerus  in  its  course  to  the  deltoid 
niuscle,  is  overstretched,  and  the  injury  to  which  it  is  exposed 
may  destroy  its  fun^Hon :  a  paralysis  of  the  deltoides  results  j 
and,  consequently,  an  inability  to  elevate  the  arm  outwards,  is 
sometimes  a  consequence  of  an  injury  done  to  this  nerve  in  a 
luxation  of  the  humerus. 

The  symptoms  which  mark  a  luxation  of  the  arm  are  nu- 
merus,  and  easy  to  be  distinguished-  The  affedted  arm  is  long- 
er than  the  other :  we  convince  ourselves  of  this  fadl,  by  un-- 
dressing  the  patient,  and  examining  the  height  of  his  elbows. 
The  arm  loses  its  vertical  position,  and  Inclines  obliquely  down- 
wards and  outwards,  and  the  elbow  is  very  much  separated, 
from  the  body  if  the  luxation  be  recent.  When,  in  the  heal- 
thy state,  the  fingers  are  moved  along  the  external  part  of  the 
OS  humeri,  an  equal  resistance  is  felt  along  its  whole  length ; 
but,  in  a  case  of  luxation,  it  is  only  at  the  middle  part  that  this 
resistance  is  felt ;  on  the  upper  part,  the  integuments,  no  long- 
er supported  by  the  superior  extremity  of  the  bone,  yield  to 
the  pressure  of  the  fingers.  The  acromion  projects  ;  an  empty 
space  is  felt  under  it,  in  which  the  head  of  the  humerus  should 
be  placed  ;  the  summit  of  the  shoulder  has  lost  its  roundness  ; 
and  a  hard  tumor,  formed  by  the  head  of  the  humerus,  is 
found  in  the  axilla.  The  patient  cannot  perform  the  motion 
of  circumdudlion,  in  which  the  arm  describes  a  cone,  the  base 
of  which  is  at  the  ends  of  the  fingers,  and  the  summit  at  the 
articulation  of  the  humerus  with  the  scapula ;  neither  can 
he  bring  his  hand  to  his  head  by  describing  a  semicircular 
line  from  without  inwards.  If  we  diredl  him  to  perform 
this  motion,  he  bends  the  fore-arm,  and  stoops  his  head  to- 
wards his  hand.  It  is  often  unnecessary  to  attend  to  all 
these  circumstances,  as  the  existence  of  the  luxation  may 
be  ascertained  by  a  simple  inspection  of  the  arm,  but  especially 
by  the  change  in  its  diredlion.  However,  we  have  given  an 
ample  detail  of  all  its  charadleristic  marks,  as  it  is  well  attested 
that  uninformed  or  inattentive  surgeons  have  sometimes  been. 


OF  XUXATIONS    OF    THE    OS    HUMERI.  24J 

misfaken  in  their  diagnosis.  We  have  mentioned,  in  treating 
of  fraftures  of  the  humerus,  the  marks  by  which  luxations  of 
this  bone  downwards  are  distinguished  from  fractures  of  its 
neck. 

The  prognosis  is  uncertain  ;  for  though  very  often  no  seri- 
ous symptom  accompanies  afFeftions  of  this  kind,  still  there  may 
be  great  difficulty  in  reducing  the  bone,  and  a  paralysis  of  the 
deltoid  muscle  may  ensue.  Professor  Boyer  has  seen  three  ca- 
ses of  this  kind. 

The  means  proposed  to  efFe£l  the  reduction  are  extremely  nu- 
merous ;  and,  defeftive  as  a  great  number  of  them  are,  it  may 
be  useful  to  take  a  view  of  them,  in  order  to  point  out  what 
led  to  their  disuse.  The  most  ancient  is  the  ambc  of  Hippo- 
crates, a  machine  not  used  in  these  times,  and  scarcely  to  be 
met  with  in  the  richest  cabinets  of  surgical  apparatus.  It  is 
composed  of  a  piece  of  wood,  rising  vertically  from  a  pedestal, 
which  is  fixed  ;  with  the  vertical  piece  is  articulated,  after  the 
manner  of  a  hinge,  an  horizontal  piece,  with  a  gutter  formed 
in  it,  in  which  the  luxated  limb  is  laid,  and  secured  with  lea- 
ther strings.  The  patient  places  himself  on  one  side  of  the 
machine  ;  his  arm  is  extended  in  the  gutter,  and  secured  ;  the 
angle  formed  by  the  union  of  the  ascending  piece  and  the  ho- 
rizontal branch  is  lodged  in  his  arm-pit,  and  then  the  horizon- 
tal branch  is  depressed.  In  this  way  extension  is  made,  whilst 
the  vertical  part  makes  counter-extension,  and  its  superior  part 
tends  to  force  the  head  of  the  humerus  into  its  cavity.  But 
there  is  nothing  to  fix  the  scapula,  and  the  compression  made 
by  the  superior  part  of  the  vertical  .portion  of  the  machine 
tends  to  force  the  head  of  the  humerus  into  its  cavity  before  it 
is  disengaged  by  the  extension-,  besides,  it  compresses  the  mus- 
-cles,  stimulates  them  to  contradlion,  and  thus  re^ndcrs  the  elon- 
gation of  them  impossible. 

The  ladder  is  attended  with  the  same  inconveniences.  In 
this  process,  a  ladder,  six  or  seven  feet  high,  is  placed  vertically, 
and  fixed  in  this  situation  :  the  upper  step  is  surrounded  by  a 
linen  cloth;  the  patient  is  elevated  by  means  of  a  stool,  so  as  to 
be  able  to  pass  the  diseased  arm  over  this  step  ;  a  number  of 
assistants  take  hold  of  the  arm  hanging  on  the  opposite  side  of 
the  ladder,  and  extend  it,  whilst  the  weight  of  the  patient, 
from  under  whom  the  stool  has  been  taken,  makes  counter-ex- 
tension, and  the  step  tends,  by  pushing  upwards  the  head  of 
the  humerus,  to  force  it  into  its  cavity.  This  process  has  this 
additional  advantage,  that  the  force  canftot  be  proportioned 
to  the  resistance,  since  it  is  alv/ays  in  proportion  to  the  weight 


244  OF    LUXATIONS    OF    THE    OS    HUMERI. 

of  the  patient.  If  he  is  very  tall  and  corpulent,  the  neck  o£ 
the  humerus  may  be  fraftured. 

The  process  by  the  door  has  the  same  disadvantages  as  the  for- 
mer, and  differs  from  it  only  by  placing  the  upper  edge  of  a 
door,  instead  of  the  upper  step  of  a  ladder,  under  the  axilla. 
The  same  objeftions  may  be  made  to  the  process  in  which  two 
strong  men,  by  placing  a  stick  in  the  axilla,  and  putting  the 
ends  of  it  on  their  shoulders,  raise  the  patient  from  the  ground, 
and  keep  him  suspended,  whilst  a  number  of  assistants  draw 
the  arm  downwards. 

Similar  defedls  are  found  in  many  other  machines  recommend- 
ed for  this  purpose;  that  proposed  by  J.  L.  Petit  is  not  exempt 
ifrom  them  •,  and,  notwithstanding  the  engraving  and  long  de- 
scription which  this  surgeon  has  given  of  it,  it  is  impossible  to 
•understand  its  mechanism.  Independently  of  the  great  pres- 
sure which  it  makes  on  the  muscles,  the  force  with  which  it  a^Tls 
is  difficultly  appreciated. 

It  has  been  also  proposed  to  extend  the  patient  on  a  carpet 
spread  on  the  floor,  while  the  surgeon,  extended  also,  but  with 
his  feet  towards  the  head  of  the  patient,  places  his  left  heel  in 
the  axilla,  and  presses  with  it  on  the  head  of  the  humerus, 
and,  at  the  same  time,  draws  the  arm  with  all  his  force.  But 
the  arm  being  parallel  to  the  trunk,  it  becomes  difficult  to  dis- 
engage the  head  of  the  humerus ;  the  heel  compresses  the  mus- 
cles, and  there  is  nothing  to  fix  the  scapula. 

Lastly,  it  has  been  recommended  to  place  the  patient  and  sur- 
geon seated  opposite  one  another,  with  the  hand  of  the  former 
secured  between  the  knees  of  the  latter  ;  this  being  done,  the 
surgeon  inclines  backwards,  and  brings  with  him  the  hand 
squeezed  between  the  knees,  whilst  with  his  hands  he  endea- 
vours to  restore  the  head  of  the  humerus.  It  is  easily  perceived 
that  the  operator  can,  in  this  situation,  exert  but  very  little 
force:  and,  if  this  process  has  succeeded  in  some  cases,  it  is 
because  the  reduction  was  very  easy,  and  would  have  been  ac- 
complished by  any  means,  even  the  least  rational. 

The  method  we  are  now  to  describe  is  by  much  the  least  ex- 
ceptionable :  its  effe^ls  are  not  contrary  to  any  of  all  the  rules 
laid  down  in  treating  of  the  general  therapeutics  of  luxations. 

A  large  piece  of  old  linen,  rolled  up  in  a  bundle,  or,  still  bet- 
ter, a  broad  cushion  of  oaten  chaff,  folded  on  itself,  is  to  be 
placed  as  high  as  possible  in  the  hollow  of  the  arm-pit ;  the 
bundle  ought  to  be  big  enough  to  fill  the  entire  hollow,  and  to 
reach  beyond  the  borders  of  it  in  such  a  m«nner  as  to  diminish 
the  pressure  made  on  the  tendons  of  the  pe<Storalis  major,  latis . 


OF    LUXATIONS    OF    THE    OS    HUMERI.  245 

simus  dorsi,  and  teres  major,  by  counter  extension.  A  sheet 
or  table-cloth,  folded  longitudinally  to  about  four  fingers  breadth, 
is  used  for  making  counter-extension  ;  the  middle  of  this  is  ap- 
plied on  the  cushion,  and  the  ends  of  it,  carried  obliquely  be- 
fore and  behind  the  breast  to  the  opposite  shoulder,  are  com- 
mitted to  assistants.  This  part  of  the  apparatus  fixes  the  trunk, 
and  even  the  scapula,  to  a  certain  degree ;  but  this  bone,  un- 
compressed towards  the  middle  of  its  external  border,  would 
yield  to  the  extending  force,  and  the  redudtion  would  be  im- 
practicable, if  it  were  not  fixed  in  the  following  manner :  a 
napkin,  folded  longitudinally,  to  about  three  fingers  breadth, 
is  applied  across  the  top  of  the  shoulder,  and  one  or  two  assist- 
ants take  the  ends  of  it,  which  are  brought  horizontally  before 
and  behind  the  breast  to  the  other  side  of  the  trunk;  and  lastly, 
another  assistant  presses  the  acromion  from  above  downwards, 
and  prevents  the  folded  napkin  from  moving  out  of  its  place. 

Extension  is  made  by  assistants,  who  pull  by  a  napkin,  folded 
diagonally,  and  tied  round  the  wrist  of  the  patient.  Every 
thing  being  thus  arranged,  and  the  patient  seated,  the  surge- 
on places  himself  on  the  external  side  of  the  arm,  dire(Sls  the 
proceedings,  attends  to  the  elongation  of  the  muscles,  and, 
when  he  sees  them  yield  to  the  extending  efi^orts,  conducSts  the 
head  of  the  bone  into  its  cavity.  The  two  hands  placed  on  the 
internal  and  superior  part  of  the  arm  are  sufiicicnt  for  this  pur- 
pose j  a  napkin  passed  under  the  patient's  arm  and  round  the 
neck  of  the  surgeon  would  be  both  embarrassing  and  useless. 
The  assistants  employed  for  making  extension  draw  first  in  an 
oblique  direcSlion  downwards  and  outwards  ;  but,  apprised  by 
the  surgeon,  they  bring  the  arm  at  the  proper  time  in  its  natu- 
ral direction,  whilst  he  forces  upwards  and  outwards  the  head 
of  the  humerus.  That  the  coaptation  may  be  made  with  the 
greatest  advantage  possible,  the  operator  should  convert  the  hu- 
merus into  a  lever  of  the  third  species,  the  inferior  part  of  which 
is  supported  against  his  breast.  The  effort  of  the  assistants  who 
extend  the  arm  is  to  co-operate  with  that  of  the  operator,  who 
dire£ls  all  the  proceedings.  When  the  muscles  are  sufficiently 
elongated,  and  the  head  of  the  bone  disengaged,  the  elbow  is 
brought  inwards  and  forwards,  in  order  to  give  the  humerus  its 
natural  direction.  This  is  to  be  done  without  suspending  the 
extension,  tlie  cessation  of  which  would  allow  the  muscles  to 
reassume  their  power,  and  bring  back  the  head  of  the  humerus 
to  the  place  from  which  it  had  been  disengaged. 

When  the  first  attempts  at  reduction  fail,  bleedings  and  warm 
Jjaths  are  to  be  had  recourse  to  j  and,  after  these  have  had  their 


■246  OF    LUXATIONS    OF    THE    OS    HUMERI. 

■effe^l,  the  patient  Is  to  be  placed  on  a  strong  and  firmly  fixed 
table,  anJ  the  operation  is  to  be  recommenced.  By  repeating 
the  attempts,  the  muscles  are  fatigued,  their  force  is  exliausted, 
and  the  reduction  is  rendered  more  easy.  If,  at  the  end  of 
some  days,  after  repeated  endeavours,  and  inducing  debility  by 
the  usual  means,  even  by  the  excessive  use  of  spirits  and  opi- 
um, we  are  not  successful,  we  advise  the  patient  to  call  in  o- 
ther  pradlitioners  ;  but  in  no  case  or  under  no  circumstances 
are  pullies  or  other  extending  machines  of  this  kind  to  be  used. 
I  have  seen  in  a  department  distant  from  the  capital,  a  patient, 
absolutely  tortured  by  the  violent  means  that  were  employed  to 
reduce  a  luxation  of  his  arm,  and  yet  the  reduction  was  not  ac- 
complished. The  patient,  an  adult,  strong  and  robust,  was 
stretched  on  a  bench,  and  held  down  by  a  number  of  men  ; 
a  band  passed  round  the  inferior  part  of  the  luxated  arm,  was 
tied  to  a  vine- press,  which  was  turned  by  twelve  men ;  but 
scarcely  had  they  put  the  machine  in  motion,  when  the  skin 
of  the  shoulder  and  arm-pit  cracked  in  many  places ;  the  la- 
ceration would  have  been  more  considerable,  or  indeed  the 
arm  would  have  been  torn  from  the  body,  if  the  assistants  who 
were  employed  to  hold  down  the  patient  had  remained  deaf 
to  his  cries. 

Citizen  Boyer  has  seen  the  same  consequences  from  similar 
attempts  to  reduce  an  old  luxation  of  the  humerus.  The  bands 
for  making  counter-extension  were  fixed  to  a  post,  and  exten- 
sion was  made  by  a  pulley.  The  pedtoralis  major,  latissimus 
dorsi,  and  teres  major,  were  not  elongated  in  the  smallest  de- 
gree, and  the  attempt  was  given  up,  without  accomplishing  the 
reduction,  though  the  force  employed  was  so  considerable  as  to 
lacerate  the  skin,  and  produce  the  most  exquisite  torture.  It 
has  been  supposed  that  the  narrowness  of  the  opening  through 
^vhich  the  head  of  the  humerus  has  escaped,  might  resist  its  re- 
duction ;  and  in  cases  where  this  obstacle  is  susped^ed,  surgeons 
have  direcied  to  move  the  luxated  arm  in  a. variety  of  diredlions, 
in  order  to  make  the  opening  wider  by  increasing  the  laceration. 
But,  independently  of  the  difficulty  of  ascertaining  the  rea- 
lity of  this  cause,  how  can  the  opening  through  which  the 
head  of  the  bone  has  escaped,  be  too  little  at  the  end  of  a  few- 
hours  to  re-ndmit  it  ?  Is  not  the  effect  of  this  practice,  in  cases 
T\'here  this  obstacle  has  been  supposed,  to  be  attributed  to  the 
lassitude  of  the  muscles  that  it  produces,  rather  than  to  an  en- 
largement of  the  laceration  in  the  orbicular  ligament  ? 

We  have  said,  in  treating  of  luxations  in  general,  that  at 
the  end  of  a  month  or  six  v/eeks,  reduction  is,  if  not  impossi- 


OF    LUXATIONS    OF    THE    OS    HUMERI.  247 

ble,  at  least  very  difficult  -,  and  we  have  pointed  out  tlie  me- 
thod to  be  pursued  when  this  operation  is  attempted  in  these  ca- 
ses. 

Luxation  of  the  humerus  inwards  may  be  primary  or  secon- 
dary. If  a  person  fall  from  a  height  on  his  elbow  placed  out- 
wards and  backwards,  the  a6lion  of  the  muscles  co-operates 
with  the  effe£ls  of  the  fall,  and  both  force  out  the  head  of  the  " 
humerus  at  the  anterior  and  internal  part  of  its  cavity,  and  pro- 
pel it  into  the  fossa  subscapularis  between  the  scapula  and 
subscapularis  muscle.  In  this  luxation,  the  external  edge  of 
the  subscapularis  is  moved  from  tlie  fossa  by  the  head  of  the 
humerus,  which  lacerates  even  the  texture  of  this  muscle, 
when  the  violence  has  been  great,  and  the  luxation  elfeiSled 
with  rapidity.  As  to  secondary  luxations  in  this  direiStion, 
they  take  place  when  the  head  of  the  humerus  deserts  the 
part  of  the  scapula  on  which  it  was  placed  in  a  luxation  down- 
wards, and  is  drawn  by  the  adlion  of  the  muscles,  parti- 
cularly by  that  of  the  pedioralis  major,  along  the  fossa  subsca- 
pularis, and  under  the  subscapularis  muscle  to  the  inferior  side 
of  the  clavicle. 

Some  have  believed  that  the  head  of  the  humerus  might  be 
carried  upwards  towards  the  clavicle,  and  be  placed  between  the 
great  pectoral  muscle  and  the  subscapularis  ;  but  the  relations 
of  the  latter  muscle  with  the  internal  side  of  the  articulation 
are  such,  that  it  should  be  turned  under  the  head  of  the  hu- 
merus before  a  secondary  luxation  could  take  place  in  this  di- 
rection. The  subscapularis,  carried  inwards,  remains  always 
at  the  internal  side  of  the  head  of  the  humerus  ;  and  if  this 
latter  part  ascends  near  to  the  coracoid  process,  it  can  only  do 
so  by  sliding  between  the  subscapularis  muscle  and  the  fossa  of 
the  same  name  :  in  that  case,  the  hard  and  round  tumor  which 
is  felt  below  the  clavicle  and  before  the  point  of  the  shoulder, 
is  formed  by  the  head  of  the  humerus,  covered  not  only  by  the 
peifloralis  major  and  minor,  but  also  by  the  subscapularis. 

In  the  luxation  of  the  humerus  inwards,  the  arm  preserves 
nearly  its  natural  length,  unless  the  head  of  the  bone  be  brought 
secondarily  towards  the  clavicle,  in  which  case  it  is  shortened. 
The  elbow  is  placed  outwards  frcun  the  body,  and  carried 
backwards  ;  a  bony  eminence  is  felt  at  the  superior  and  external 
part  of  the  breast,  before  the  point  of  the  shoulder,  and  below 
the  clavicle  ;  there  is  no  tumour  in  the  axilla;  the  point  of  the 
shoulder  is  more  round,  and  the  acromion  is  L"„s  prominent 
than  in  luxations  downwards  j  l^tly,  the  motion  of  circiunduc- 
Uon  is  impossible. 


•248  OF    LUXATIONS    01-     THE    OS    HUMERI. 

The  prognosis  is  more  unfavourable  in  this  luxation  than  irf 
that  downwards  j  the  straining  of  the  parts  has  been  greater, 
the  laceration  more  considerable,  and  the  reduction  is  more  dif- 
ficult ;  it  is  particularly  difficult  when  the  luxation  is  of  a  long 
standing,  and  of  the  secondary  kind.  The  head  of  the  bone, 
in  these  circumstances,  often  grows  to  the  superior  part  of  the 
fossa  subscapularis.  The  process  for  reducing  it  is  the  same  as 
that  used  in  the  luxation  downwards,  with  this  slight  difference  : 
the  assistants  who  extend  the  arm  are  to  pull  at  first  in  the  di- 
rection of  the  elbow  which  was  carried  backwards,  and  not 
bring  it  forwards  but  at  the  moment  when  the  head  of  the  bone 
is  disengaged  from  the  muscle  and  the  fossa  subscapularis.  If 
the  luxation  be  secondary,  we  are  first  to  endeavour  to  bring 
the  head  of  the  humerus  downwards  into  the  hollow  of  the 
arm-pit,  and  then  replace  it  as  in  cases  of  luxation  downwards. 

There  is  no  well-attested  instance  of  luxation  of  the  hume- 
rus outwards  or  backwards,  though  many  authors  appear  to  have 
admitted  the  possibility  of  it.  It  cannot  take  place  secondarily, 
and  succeed  to  a  luxation  downwards,  because  the  tendon  of 
the  long  portion  of  the  triceps  opposes  it.  Should  a  fall  on 
the  elbow  placed  inwards  and  forwards  produce  it  primarily, 
the  head  of  the  humerus  would  be  carried  into  the  fossa  infras- 
pinalis  between  the  external  part  of  this  fossa  and  the  infraspi- 
pinatus  and  teres  minor  muscles.  The  resistance  of  the  spine 
of  the  scapula  would  prevent  the  humerus  from  ascending  so 
high  as  to  occasion  a  shortness  of  the  arm ;  but  the  elbow 
would  be  placed  inwards  and  forwards.  The  acromion  would 
projeft,  especially  anteriorly  ;  an  eminence  would  be  felt  be- 
hind the  shoulder  below  the.  spine  of  the  scapula  ;  the  motion 
of  the  humerus  would  be  painful,  and  that  of  circumducHrion 
impossible.  It  is  to  be  reduced  according  to  the  rules  already 
laid  down  ;  but  the  arm  is  to  be  drawn  at  first  inwards  and  for- 
wards, in  order  to  disengage  the  head  of  the  bone  before  bring- 
ing it  to  its  natural  diredlion. 

Whatever  may  be  the  kind  of  luxation,  the  reduced  bone  is 
easily  kept  in  its  place,  by  preventing  the  motion  of  the  arm  ; 
and  as  luxation  can  take  place  only  when  the  arm  is  at  some 
distance  from  the  trunk,  a  return  of  it  will  be  certainly  pre- 
vented by  tying  the  elbow  to  the  side.  A  bandage  carried  se- 
veral times  round  the  trunk,  and  including  the  elbow,  answers 
this  purpose.  The  spica  bandage  applied  to  the  point  of  the 
shoulder  would  not  answer  so  well  the  proposed  end  5  its  action, 
from  being  confined  to  the  superior  extremity  of  the  humerus. 


OF    LUXATIONS    OF    THE    OS   HUMERI.  249 

would  not  prevent  the  motion  of  the  elbow;  consequently  we 
find,  that  it  is  now  only  used  to  retain  emollient  and  resolvent 
topical  applications,  which  it  is  sometimes  necessary  to  app'y  to 
the  shoulder.  Different  symptoms  which  may  accompany  or 
succeed  luxations  of  the  humerus,  such  as  pain,  paralysis  of  the 
deltoid  muscle,  or  oedema  of  the  arm,  may  render  such  topical 
applications  necessary. 

If  the  shoulder  be  much  contused,  and  the  pain  considerable, 
emollient  cataplasms  are  to  be  applied  to  the  pained  part  j  and 
if  the  patient  be  young  and  strong,  some  blood  is  to  be  taken 
away.  When,  by  this  treatment,  the  pain  is  diminished,  the 
emollients  are  to  be  replaced  by  resolvents,  with  a  view  of  dis- 
cussing the  ecchymosis.  In  the  generality  of  cases,  the  pain 
has  entirely  vanished,  and  the  patient  has  recovered  the  entire 
use  of  his  arm  at  the  end  of  a  month. 

The  cedema  may  arise  from  the  compression  made  by  the 
head  of  the  humerus  in  the  axilla  on  the  veins  and  lymphatic 
vessels,  which  bring  back  the  fluids  of  the  superior  extremity. 
The  round  figure  of  the  head  of  the  humerus  and  its  polished 
•surface  render  it  unfit  for  making  great  pressure,  so  that  it  slides 
easily  over  the  soft  parts,  and  seldom  produces  this  symptom. 
Paralysis  is  much  more  frequently  met  with,  and  it  would  be  a 
much  more  frequent  consequence  if  the  brachial  plexus  and  ax- 
illary vessels  did  not  easily  escape  from  the  round  and  slippery 
surface  of  the  head  of  the  humerus.  If  these  nerves  are  slightly 
compressed  by  this  bony  eminence,  a  numbness  and  pain  are 
felt  in  the  arm,  but  these  symptoms  diappear  on  the  reduction 
being  accomplished.  This  is  not  the  case  with  the  paralysis 
produced  by  the  contusion  and  disorganization  of  the  plexus  ; 
it  often  resists  the  application  of  the  most  powerful  remedies  j 
however,  the  effe£ls  of  blisters  and  fri(ftions  with  irritating  sub- 
stances, such  as  the  tindliure  of  cantharides,  may  be  tried.  I 
have  seen  much  benefit  arise  in  these  cases  from  burning  moxa 
behind  the  clavicle,  and  immediately  above  the  brachial  plexus. 

The  paralysis,  as  we  have  mentioned,  is  sometimes  confined 
to  the  deltoid  muscle.  It  depends  then  on  the  contusion  and  in- 
jury done  to  the  circumflex  nerve  by  the  head  of  the  humerus 
which  bends  it  under  it.  This  afleftion  is  sometimes  very  ob- 
stinate, resists  the  usual  remedies,  and  is  followed  by  a  diminu- 
tion of  volume  in  the  muscle. 

Lastly,  there  is  an  accident  which  may  arise  from  the  efforts 
to  reduce  a  luxation,  with  which  the  praflitloner  ought  to  be 
made  acquainted,  in  order  that  he  may  not  be  alarmed  at  its 
32 


afO  OF    LUXATIONS    OF    THE    OS   HUMERI. 

taking  place.  It  is  generally  produced  by  the  violent  efforts 
nece(^ary  to  reduce  an  old  luxation,  and  it  was  in  a  case  of  this 
kind  that  it  presented  itself  to  Desault.  This  surgeon,  after 
reducing  with  great  difficnlty  a  luxation  inwards,  which  had 
continued  for  six  weeks,  perceived  a  tumour  forming  rapidly  un- 
der the  great  pedtoral  muscle,  which  soon  extended  to  the  ax- 
illa, and  filled  its  entire  cavity.  Desault  and  his  assistants 
thought  that  an  aneurism  was  produced  by  the  rupture  of  an 
artery:  but  their  apprehensions  were  soon  removed.  It  after- 
wards appeared  that  the  tumour  was  formed,  according  to  the 
opinion  of  some,  by  an  effusion  of  venous  blood ;  according  to 
that  of  others,  by  air  escaping  from  the  lungs ;  but  the  former 
appears  by  much  the  most  probable,  as  the  tumour  disappeared  on 
the  thirteenth  day,  and  left  a  large  ecchymosis,  which  was  not 
discussed  before  the  twenty-seventh  day. 

Anchylosis  is  never  a  consequence  of  luxations  of  the  hume- 
rus, when  they  are  reduced.  The  motion  of  the  arm,  first 
impeded  by  the  pain,  becomes  daily  more  free,  and  is  soon 
performed  with  as  much  facility  as  before  the  luxation  had  ta- 
ken place.  The  recovery  of  the  patient  is  accelerated  by  mo-  ' 
ving  the  arm  every  day  as  much  as  the  state  of  the  soft  parts  sur- 
rounding the  articulation  will  admit.  It  is  even  rare  to  find  an 
anchylosis  in  luxations  of  the  arm  which  have  not  been  reduced. 
The  head  of  the  humerus  makes  a  depression  in  the  part  of  the 
scapula  with  which  it  is  in  contaft,  and  forms  a  new  articulation, 
which  allows  more  or  less  extensive  motion  j  but  it  will  be  Tor 
ever  impossible  to  carry  the  hand  semicircularly  to  the  head» 


251 


CHAPTER  X. 


OF  LUXATIONS  O^  THE  FORE-ARM. 

THIS  chapter  will  be  divided  into  three  sections :  in  the 
first  we  will  treat  of  luxations  of  both  bones  of  the  fore- 
arm from  the  humerus ;  in  the  second  we  will  describe  luxation 
of  the  superior  extremity  of  the  radius  from  the  ulna,  and  in 
the  third  we  will  treat  of  luxations  of  the  inferior  extremity  of 
the  ulna  from  the  radius. 


SECTION   I. 


t)f  Luxations  of  the  Tore-arm  from  the  Humerus  % 

Notwithstanding  the  extent  of  the  surfaces  of  the  articu- 
lation of  the  radius  and  ulna  with  the  os  humeri,  the  strength 
of  the  muscles  and  ligaments  surrounding  it,  and  the  mutual 
reception  of  the  eminences  which  makes  it  a  perfedl  angular 
ginglymus,  a  dislocation  of  these  two  bones  from  the  extremity 
of  the  humerus  may  take  place  at  the  same  time.  They  are 
luxated  for  the  most  part  backwards,  sometimes  laterally,  but 
very  rarely  anteriorly :  the  latter  luxation  cannot  take  place 
tfithout  a  fradlure  of  the  olecranon.  Luxation  backwards  is 
the  most  frequent :  it  is  facilitated  by  the  small  size  of  the  co- 
tonoid  process,  which,  when  the  extremity  of  the  humerus  is 
forcibly  pushed  downwards  and  forwards,  may  slide  behind  it, 
and  mount  up  even  to  the  cavity  which  receives  the  olecranon 
during  the  extension  of  the  fore-arm. 

Luxations  latterly  are  much  less  frequent,  and  are  always  in- 
complete. The  great  extent  of  the  articulating  surfaces  in  their 
transverse  direilion,  the  reciprocal  union  of  their  inequalities. 


252  OF    LUXATION    OF    THE    FORE-ARM 

and  especially  the  strength  of  the  ligaments  and  muscles,  which 
arising  from  the  internal  and  external  condyles  of  the  inferior 
extremity  of  the  humerus,  go  to  the  fore-arm  and  hand,  give 
great  strength  to  the  articulation,  and  render  it  impossible  to 
effeOi  by  any  violence  a  complete  luxation  laterally. 

In  the  luxation  backwards,  the  radius  and  ulna  may  ascend 
niore  or  less  behind  the  humerus  5  but  the  coronoid  process  of 
the  ulna  is  always  carried  above  the  articular  pulley,  and  is 
found  lodged  in  the  cavity  destined  to  receive  the  olecranon. 
The  head  of  the  radius  is  placed  behind  and  above  the  external 
condyle  of  the  humerus.  The  annular  ligament,  "which  con- 
lines  the  superior  extremity  of  the  radius  to  the  ulna,  may  be 
lacerated  :  in  which  case,  even  when  the  bones  are  reduced,  it 
is  difficult  to  keep  them  in  their  proper  places,  as  the  radius 
tends  constantly  to  separate  from  the  ulna. 

This  luxation  always  takes  place  from  a  fall  on  the  hand ;  for, 
when  we  are  falling,  we  are  led  by  a  mechanical  instinct  to  bring 
our  hands  forrvards  to  prote£l  the  body.  If,  in  this  case,  the  su- 
perior extremity,  instead  of  resting  vertically  on  the  ground, 
be  placed  obliquely  with  the  hand  nearly  in  a  state  of  supination* 
the  repulsion  which  it  receives  from  the  ground  will  cause  the 
two  bones  of  the  fore-arm  to  ascend  behind  the  humerus, 
vfhilst  the  weight  of  the  body  pressing  on  the  humerus 
dire£led  obliquely  downwards,  forces  its  extremity  to  pass  down 
before  the  coronoid  process  of  the  cubitus. 

The  fore-arm  in  this  luxation  is  in  a  state  of  demi-flexion, 
and  every  attempt  to  extend  it  occasions  smart  pains.  The  si- 
tuation of  the  olecranon,  with  respe<ft  to  the  condyles  of  the 
humerus,  is  changed.  The  olecranon,  which  in  the  natural 
state  is  placed  on  a  level  with  the  external  condyle,  which  is 
itself  situated  lower  than  the  internal,  is  higher  than  it. 

This  luxation  may  be  mistaken  for  a  fra(^ure  of  the  olecra- 
non, of  the  head  of  the  radius,  or  even  of  the  inferior  extremity 
of  the  humerus  :  such  a  mistake  is  attended  with  very  bad  con- 
sequences -,  for  if  the  reduction  be  not  effedled  before  the  end 
of  fifteen  or  twenty  days,  it  is  impossible  to  accomplish  it  after- 
wards. Sifch  was  the  case  of  a  student  of  law,  who  fell  down 
stairs  and  luxated  his  fore-arm  backwards.  The  surgeon  to 
whom  he  applied,  thought  he  discovered  a  fradlure  of  the 
head  of  the  radius,  and  treated  him  as  if  a  fra£Vure  had  really 
taken  place ;  but  at  the  end  of  twenty  days  the  error  was  de- 
tefted,  without  a  possibility  of  reducing  the  luxation.  The 
swelling,  more  or  less  considerable,  which  supervenes  in  twenty- 
four  hours  after  the  accident,  renders  a  diagnosis  difficult  i  the 


FROM    THE    HUMERUS.  253 

the  bony  prominences  are  so  covered  by  it,  that  it  is  impossi- 
ble to  examine  their  respedlive  situations.  Besides,  the  rubbing 
of  the  coronoid  process  and  olecranon  against  the  humerus, 
causes  a  grating  noise  similar  to  that  in  fradlure.  From  these 
circumstances  it  must  appear,  that  much  attention  is  requisite 
to  establish  a  diagnosis  between  fra<5lure  of  the  head  of  the  ra- 
dius, and  dislocation  of  the  fore-arm  backwards. 

Different  methods  have  been  proposed  to  reduce  this  luxa- 
tion of  the  fore-arm  :  some  diredt  to  place  the  elbow  of  the 
patient  on  a  table  covered  with  many  folds  of  cloth ;  while  the 
surgeon  places  his  elbow  in  the  bend  of  the  arm,  insinuates 
his  fingers  between  those  of  the  patient,  and  bending  his  fore- 
arm draws  up  the  hand,  and  presses  at  the  same  time  with  his 
elbow  on  the  inferior  part  of  the  humerus.  But  the  force  that 
can  be  applied  in  this  way  is  inconsiderable  ;  besides,  the  pres- 
sure forces  the  inferior  extremity  of  the  humerus  against  the 
luxated  bones,  increasing  the  fri<ftion  and  the  difficulty  of  reduc- 
tion. The  same  inconvenience  attends  the  method  which  con- 
sists in  placing  the  fold  of  the  luxated  arm  against  a  bed-post, 
and  bending  the  arm  by  means  of  an  assistant,  while  the  surgeon 
pushes  the  olecranon  downwards  and  forwards. 

The  following  method  is  by  much  preferable.  The  patient 
being  firmly  seated,  an  assistant  seizes  the  middle  part  of  the 
humerus,  and  makes  counter-extension,  while  another  assistant 
makes  extension  by  drawing  by  the  inferior  part  of  the  fore-arm; 
the  surgeon,  seated  on  the  outside,  grasps  the  elbow  with  his 
two  hands,  by  applying  the  four  fingers  of  each  hand  to  the 
anterior  part  of  the  humerus,  and  the  thumbs  to  the  posterior, 
Avith  which  he  presses  on  the  olecranon,  in  a  direction  down- 
wards and  forwards.  This  method  will  be  in  general  successful. 
If  the  strength  of  the  patient,  or  the  long  continuance  of  the 
luxation,  render  it  necessary  to  employ  a  greater  force,  a  fillet 
is  to  be  applied  on  the  wrist  to  make  extension,  and  a  cushion 
is  to  be  placed  in  the  axilla,  and  the  arm  and  trunk  fixed  as  is 
done  in  cases  of  luxation  of  the  humerus. 

When  the  luxation  is  reduced,  which  is  known  by  the  noise 
the  bones  make  in  reassuming  their  situation,  by  the  relative 
position  of  the  processes,  by  the  form  of  the  part,  and  the  fa- 
cility of  flexion  and  extension,  long  compresses  moistened  with 
a  resolvent  Uquid,  are  to  be  applied  to  the  elbow.  They  should 
be  arranged  obliquely,  so  as  that  their  extremities  may  cross 
one  another,  and  the  whole  form  a  figure  of  8,  which  arrange- 
ment will  prevent  them  from  falling  off.     The  fore-arm  is  to 


254  OF    LUXATIONS    OF    THE  FORE-ARM 

be  neither  much  bent  nor  extended.  A  roller  is  to  be  passed 
tightly  round  the  hand  and  fore-arm,  in  order  to  prevent  an  ef- 
fusion of  lymph.  The  laceration  which  always  takes  place,  is 
accompanied  with  more  or  less  inflammatory  swelling,  which  is 
to  be  combated  by  blood-lettings,  emollient  cataplasms,  ano- 
dynes, resolvents,  &c. 

At  the  end  of  seven  or  eight  days,  when  the  inflammatory 
symptoms  are  nearly  gone,  the  articulation  Is  to  be^  gently  mo- 
ved, and  the  motion  is  to  be  increased  every  day,  in  order  to 
prevent  anchylosis,  to  which  it  is  remarkably  disposed. 

In  a  luxation  of  the  fore-arm  backwards,  the  annular  liga- 
ment which  confines  the  head  of  the  radius  to  the  extremity  of 
the  ulna  is  sometimes  torn,  and  the  radius  passes  before  the  cu- 
bitus. In  such  cases  the  motions  of  pronation  and  supinatioii 
are  difficult  and  painful,  though  the  principal  luxation  has  been 
reduced.  The  head  of  the  radius  may  be  easily  replaced,  by 
pressing  It  from  before  backwards,  and  it  is  kept  in  its  place  by 
adding  to  the  apparatus  above  described,  a  compress,  which  is 
to  be  applied  to  the  superior  and  external  part  of  the  fore-arm. 
The  bandage  and  compresses  are  to  be  taken  off  every  two  or 
three  days,  and  re-applied  :  this  precaution  is  very  necessary, 
on  account  of  the  relaxation  of  the  bandages,  and  the  necessity 
of  moving  the  articulation  to  prevent  an  anchylosis. 

If  the  luxation  be  not  soon  reduced,  it  becomes  irreducible  ; 
the  superior  extremities  of  the  bones  of  the  fore-arm  grow  to 
the  humerus  at  its  posterior  part,  and  the  patient  can  neither 
bend  nor  extend  his  arm.  However,  in  some  cnses,  especially 
in  young  persons,  some  motion  is  acquired  in  time,  the  heads 
of  the  radius  and  ulna  make  depressions  in  the  humerus,  and 
form  for  themselves  cavities,  in  which  they  perform  some  mo- 
tions, but  always  imperfedlly. 

The  luxation  forwards  should  be  treated  as  a  fradlure  of  the 
olecranon,  with  which  it  would  be  inevitably  accompanied.  It 
may  be  necessary,  on  account  of  the  great  injury  done  to  the 
soft  parts,  to  bleed  the  patient  copiously,  and  put  him  on  an 
antiphlogistic  regimen. 

As  to  the  lateral  luxations,  either  inwards  or  outwards,  they 
are  always  incomplete,  and  easily  discovered.  They  are  redu- 
ced by  drawing  the  humerus  and  fore-arm  in  contrary  direftions, 
and  at  the  same  time  pushing  the  extremity  of  the  humerus 
and  the  two  bones  of  the  fore-arm  in  opposite  direftions.  The 
extension  and  counter-extension  diminish  the  fri<ftion  of  the 
surfaces  of  the  articulation,  and  facilitate  their  sliding  over  one 
another. 


FROM    THE    HUMERUS.  255 

These  luxations  cannot  be  produced  without  considerable  vi- 
olence ;  but  when  the  bones  are  reduced,  they  are  easily  kept 
in  their  place.  It  will  be  sufficient  to  pass  a  roller  round  the 
part,  to  put  the  fore-arm  in  a  middle  state,  neither  much  bent 
nor  extended,  and  to  support  it  in  a  sling.  But  much  inflam- 
mation is  to  be  expected,  from  the  injury  done  to  the  soft  parts. 
In  order  to  prevent  it,  or  at  least  mitigate  it,  the  patient  is  to 
be  bled  two  or  three  times,  and  put  on  a  low  diet,  and  the  ar- 
ticulation is  to  be  covered  with  emollient  cataplasms.  It  is 
scarcely  necessary  to  repeat  that  the  arm  is  to  be  moved  as  soon 
is  the  state  of  the  soft  parts  will  admit  of  it. 


SECTION    H. 


Of  Luxations  of  the  superior  Extremity  of  the  Radius  from  the  Ulna. 

The  two  bones  of  the  fore-arm,  articulated  laterally  by  a 
double  ginglymus,  may  be  luxated  from  one  another.  But  of 
these  dislocations,  of  which  the  ancients  make  no  mention, 
there  is  none  more  frequent  than  that  of  the  head  of  the  ra- 
dius from  the  ulna.  The  superior  extremity  of  the  former  may 
be  forced  before  or  behind  the  little  sigmoid  cavity  of  the  ulna, 
destined  to  lodge  a  part  of  its  circumference.  They  may  take 
place  instantaneously,  from  a  violent  and  sudden  effort,  or  gra- 
dually j  and  on  account  of  this  difference,  they  are  divided  in- 
to primary  and  secondary.     We  will  treat  first  of  the  primary. 

Though  the  superior  extremity  of  the  radius,  in  its  different 
motions  round  the  ulna,  turns  on  its  own  axis,  yet  different  ob- 
servations prove  that  this  extremity  of  the  bone  may  be  dislo- 
cated. The  possibility  of  its  luxation  forwards,  which  ought 
to  be  rarer  than  that  backwards,  is  easily  conceived.  The  cause 
of  the  one  being  more  frequent  than  the  other  may  be  this ; 
the  motion  of  supination,  which  must  take  place  to  produce  lux- 
ation forwards,  is  less  free  and  less  extensive  than  that  of  pro- 
nation, in  which  the  luxation  backwards  is  effe^ed ;  besides, 
the  little  sigmoid  cavity  in  the  ulna  presents  anteriorly  on  its 
margin  a  bony  prominence,  which  prevents  in  some  degree  the 
head  of  the  radius  from  passing  on  that  side. 

Many  cases  of  primary  luxation  of  the  radius  backwards  are 
found    in  the  work  of  Duverney.     Citizen  Boyer   has   met 


256  OF    LUXATIONS    OF    THE    RADIUS. 

with  it  twice  in  a  child  of  ten  or  twelve  years  of  age.  I  have 
seen  a  similar  afFeftion,  in  a  child  of  the  same  age,  in  conse- 
quence of  a  fall.  In  this  luxation,  the  hand  is  irj  the  state  of 
pronation,  and  cannot  be  brought  to  its  natural  state,  which  is 
the  medium  between  pronation  and  supination.  The  eminence 
formed  by  the  head  of  the  radius,  instead  of  being  felt  under  the 
external  condyle  of  the  humerus,  is  placed  behind  at  the  external 
side  of  the  olecranon.  A  depression  is  felt  at  the  superior  and  ex- 
ternal part  of  the  fore-arm.  In  order  to  reduce  it,  the  left  hand  is 
to  be  placed  on  the  elbow,  so  as  to  be  able  to  push  with  it  the 
head  of  the  radius  from  behind  forwards,  and  the  patient's 
hand  is  to  be  taken  by  the  other  and  brought  towards  supina- 
tion, while  the  displaced  extremity  is  pushed  forwards.  The 
noise  heard  at  the  moment  that  the  extremity  of  the  radius 
enters  the  sigmoid  cavity,  the  remission  of  the  pain,  the  change 
in  the  shape,  and  the  facility  of  performing  pronation  and  su- 
pination, indicate  that  the  luxation  has  been  reduced.  The 
after-treatment  consists  in  surrounding  the  part  with  compresses, 
wet  with  resolvent  liquids,  and  in  covering  the  entire  limb 
with  a  roller  The  articulation  should  be  frequently  moved, 
but  always  very  gently,  as  the  annular  ligament  unites  with, 
difficulty,  and  only  after  a  long  time. 

The  secondary  luxation  of  the  superior  extremity  of  the 
radius,  arises  from  small  efforts  often  repeated,  which,  without 
immediately  displacing  the  bone,  disposes  it  to  relinquish  gra- 
dually the  sigmoid  cavity.  It  takes  place  in  young  children. 
Nurses  generally  take  children  by  the  hand  when  they  walk, 
to  prevent  them  from  falling;  and  when  they  are  in  danger  of 
falling,  support  them  by  drawing  up  the  arm  with  the  hand  in 
an  overstretched  state  of  pronation.  The  same  is  done  some- 
times to  put  them  over  a  little  stream,  or  even  to  carry  them 
to  a  certain  distance.  The  straining  occasioned  in  this  way, 
produces  a  dull  pain,  which  each  repetition  of  the  pra<fl:ice  in- 
creases. The  child  complains  of  this  pain  when  the  articula- 
tion of  the  elbow  is  pressed  on.  He  makes  less  uie  of  this 
arm  than  of  the  other,  and  if  he  receives  a  sweetmeat  in  the 
hand  of  this  side,  he  passes  it  to  the  other  to  convey  it  to  his 
naouth.  In  this  state  of  the  disease,  it  will  be  only  necessary 
to  avoid  a  repetition  of  the  cause,  and  to  apply  embrocations 
to  the  part.  If  these  precautions  are  negle<fted,  and  if  the 
pra(5tice  of  raising  the  child  by  the  arnj  be  persisted  in,  the 
pain  continues  and  increases;  a  swelling  appears  in  the  pained 
joint;  the  superior  extremity  of  the  radius  is  carried  backwards; 
the  motions  of  the  fore-arm  are  obstructed,  and  usually,  in 


X)F    LUXATIONS    OF    THE    ULNA.  257 

scrofulous  children,  the  tumefaftion  of  the  joint  increases;  the 
extremities  of  the  bones  become  carious  ;  abscesses  form, 
which  either  on  breaking  spontaneously,  or  being  artificially 
opened,  cause  fistulous  openings  into  the  joint.  Then  the  dis- 
location of  the  extremity  of  the  radius  is  no  more  the  principal 
disease;  this  consists  of  a  painful  swelling  of  the  soft  parts,  and 
enlargement  and  caries  cf  the  ends  of  the  bones.  In  the  chap- 
ter on  white  swellings  we  will  give  the  treatment  of  it. 


SECTION   III; 


^  Of  Luxations  of  the  inferior  Extremity  of  the  Ulna. 

We  give  this  denomination  to  the  dislocations  of  the  Infe- 
rior extremities  of  the  bones  of  the  fore-arm,  which  other  au- 
thors describe  under  the  name  of  luxations  of  the  inferior  ex- 
tremity of  the  radius.  Although  this  extremity  moves  on  the 
ulna,  yet,  as  the  head  of  the  latter  evidently  escapes  from  the 
sigmoid  cavity  of  the  radius,  and  as,  in  considering  the  afFe<flion 
as  arising  from  this  dislocation,  it  is  easier  to  explain  the  phe- 
nomena of  it,  we  have  adopted  this  name  in  preference. 

The  inferior  extremity  of  the  ulna  may  be  luxated  anteri- 
orly, or  posteriorly,  from  the  inferior  extremity  of  the  radius. 

The  first  of  these  luxations,  of  which  we  have  but  few  exam- 
ples, must  be  much  less  frequent  than  the  second,  because  the 
excessive  supination  of  the  hand  necessary  to  produce  it  is  more 
difloicult  than  its  pronation.  It  is  well  known  that  it  is  in  the 
state  of  pronation  that  the  hand  performs  almost  all  its  motions, 
and  fulfils  the  greater  part  of  the  purposes  to  which  it  is  adapted. 
In  this  luxation,  the  head  of  the  radius  rolls  from  before  back- 
wards, or  from  within  outwards  on  the  head  of  the  ulna,  and 
pushes  it  forwards;  if  the  luxation  take  place  rapidly,  the  liga- 
ments between  the  bones  will  be  torn,  and  the  little  heati  of  the 
ulna  will  be  forced  before  the  inferior  extremity  of  the  radius. 
In  this  state,  the  hand  is  in  a  continual  state  of  supination,  and 
cannot  be  brought  to  that  of  pronation;  a  tumour  is  felt  before 
the  radius;  there  is  an  empty  space  where  the  inferior  extremity 
of  the  cubitus  should  be;  and  this  bone,  instead  of  being  pa- 
rallel with  the  radius,  crosses  it  obliquely  at  its  inferior  part. 
Redu(Sl;ion  is  easily  efi^e£led.  It  is  done  by  pulling  the  arm, 
33 


258        OF  LUXATIONS  OF  THE  ULNA. 

and  at  the  same  time  turning  it  a  little  inwards,  whilst  the 
bead  of  the  ulna  is  pushed  backwards,  and  the  extremity  of 
the  radius  carried  forwards,  the  person  who  extends  the  arm 
bringing  the  hand  at  the  same  time  to  the  state  of  pronation. 
The  noise  made  by  the  replacing  of  the  bones,  the  disappear- 
ance of  the  deformity,  and  the  facility  of  putting  the  hand  in 
the  supine  or  prone  state,  shew  that  the  luxation  is  reduced. 
Compresses  wet  with  resolvent  liquids,  and  a  roller  passed 
tightly  round  the  fore-arm,  are  all  the  apparatus  that  are  ne- 
cessary after  the  reduction;  the  hand  is  to  be  kept  at  rest  and 
supported  in  a  sling.  This  luxation,  if  negledled,  would  lead 
in  a  very  short  time  to  the  loss  of  motion  in  the  joint  from  an 
anchylosis. 

Citizen  Boyer  has  met  a  remarkable  case  of  luxation  of  the 
cubitus  anteriorly,  which  is  extremely  rare.  A  woman  engaged 
in  a  riot,  that  took  place  in  a  coffee-house  near  the  market- 
place of  Saint  Germain,  was  pushed  out  of  the  house  by  a  man 
who  twisted  her  hand  violently  in  the  supine  diredllon;  she 
felt  horrible  pain,  and  cried  out  that  her  wrist  was  breaking, 
and  In  the  moment  saw  that  a  deformity  supervened.  Profes- 
sor Boyer  was  called  in;  he  found  the  hand  fixed  in  the  supine 
state,  the  fore-arm  bent,  and  the  hand  supported  before  the 
breast.  The  oblique  diredtion  of  the  inferior  extremity  of  the 
ulna  which  crossed  the  radius,  was  very  remarkable.  The 
redudtlon  was  accomplished  only  by  the  fourth  attempt. 

The  luxation  backwards  of  the  inferior  extremity  of  the  ul- 
na, described  by  authors  under  the  name  of  luxation  forwards 
of  the  Inferior  extremity  of  the  radius,  has  been  frequently  ob- 
served. It  is  more  frequent  than  the  former,  because  the  mo- 
tion of  pronation,  by  which  It  is  occasioned,  is  more  habitual 
than  that  of  supination;  and  as  luxation  forwards  is  produced 
by  a  violent  supination,  so  that  backwards  Is  the  result  of  a 
violent  and  sudden  pronation.  Such  was  the  case  of  the  female 
mentioned  In  Desault's  Surgical  Journal,  who  luxated  the  cubi- 
tus backwards  in  wringing  wet  cloths;  in  doing  which,  the 
hands  are  put  In  the  greatest  state  of  pronation  possible.  The 
hand  In  this  luxation  Is  fixed  In  the  prone  state,  is  incapable  of 
supination,  and  Is  a  little  Inclined  inwards.  The  ulna  crosses 
the  radius  obliquely,  but  its  little  head  forms  a  tumour  behind 
the  inferior  extremity  of  this  bone.  It  is  reduced  in  the  same 
manner  as  the  luxation  forwards,  with  this  difference,  that  the 
hand  is  to  be  moved  in  a  contrary  diredllon.  If  the  luxation 
has  been  ncgledled,  and  a  swelling  of  the  articulation  has  su- 


OF    LUXATIONS   OF    THE   WRIST.  259 

pervened,  no  attempt  is  to  be  made  to  effect  a  redu£lion  until 
the  swelling  is  discussed  by  means  of  emollient  cataplasms;  we 
should  not  however  defer  the  reduftion  too  long,  as  it  often 
becomes  impossible  after  a  very  short  time.  In  the  latter  case, 
the  person  is  not  so  much  disabled  in  the  luxation  backwards, 
as  in  that  forwards;  the  state  of  pronation  being  much  more 
convenient  for  the  purposes  of  the  hand,  than  that  of  supina- 
tion. 


CHAPTER  XI. 


OF  LUXATIONS  OF  THE  HAND. 

SECTION   I. 


Of  Luxations  of  the  Wrist. 

FOUR  kinds  of  luxations  may  take  place  in  the  articulation 
of  the  bones  of  the  carpus  with  the  inferior  extremities 
of  those  of  the  fore-arm,  viz.  luxation  forwards,  backwards, 
inwards,  and  that  outwards.  But  the  two  first,  especially  that 
backwards,  are  the  most  frequent,  because  the  motions  of  flex- 
ion and  extension  are  much  more  extensive  than  those  of  ad- 
duction and  abdudlion,  and  because  the  extent  of  the  articula- 
ting surfaces  is  greater  from  within  to  the  outside,  than  from 
before  backwards ;  besides,  the  styloid  apophyses  of  the  radius 
and  ulna  strengthen  the  external  and  internal  sides  of  the  arti- 
culation, and  render  dislocation  in  the  transverse  direiStion  still 
more  difficult. 


l6o  OF    LUXATIONS    OF    THE    WRIST. 

The  articulation  of  the  hand  with  the  fore-arm  is  remarkable 
in  this,  that  it  admits  of  flexion  and  extension  nearly  to  the 
same  extent;  whilst  these  two  motions,  in  all  the  other  articu- 
lations, have  parely  the  same  latitude,  that  of  flexion  being 
always  the  most  considerable. 

Luxation  backwards  is  facilitated  by  the  direftion  of  the  con- 
vex articulating  surfaces  of  the  scaphoides,  semilunaris,  and 
pyramidalis,  which,  inclined  more  backwards  than  anteriorly, 
must  be  more  disposed  to  slide  in  this  direction  than  in  ^ny 
Other.  It  is  caused  by  a  fall  on  the  back  of  the  hand  while 
much  bent;  in  which  case  the  first  range  of  bones  of  the  wrist 
slides  backwards  into  the  oblong  cavity  of  the  two  bones  of  the 
fore-arm,  extends  and  lacerates  the  posterior  ligament,  and 
forms  an  eminence  behind  the  ends  of  the  radius  and  ulna. 
This  tumour,  the  depression  at  the  anterior  part  of  the  wrist, 
and  the  extraordinary  flexion  of  the  hand  which  cannot  be  ex- 
tended, are  the  distinguishing  marks  of  this  luxation.  It  is  re- 
duced by  fixing  the  fore-arm,  and  drawing  the  hand,  whilst 
pressure  is  made  on  the  eminence  formed  by  the  displaced  car- 
pus to  force  it  back  into  its  cavity.  An  assistant  fixes  the  arm, 
and  jjie  surgeon  makes  extension  and  adjusts  the  bones.  Lux- 
ation forwards  is  occasioned  by  a  fall  on  the  palm  of  the  hands, 
the  fingers  being  extended,  and  more  force  being  applied  to 
the  inferior  part  of  the  palm  than  to  the  superior.  It  is  rarely 
complete;  the  hand  remains  painfully  extended,  and  cannot 
be  restored  to  its  natural  direction  without  some  difliculty. 
The  numerous  tendons  which  pass  before  the  wrist,  and  the 
annular  ligament  which  confines  them,  being  pushed  forwards, 
render  it  so  difficult  to  discover  the  eminence  formed  by  the 
bones  of  the  wrist  before  the  ends  of  those  of  the  fore-arm, 
that  this  affe<5lion  may  be  easily  mistaken  for  a  sprain.  Conse- 
quently, in  all  doubtful  cases,  we  should  proceed  as  if  the  lux- 
ation had  really  taken  place,  and  bring  the  hand  into  its  proper 
direction. 

Luxations  backwards,  but  especially  those  forwards,  are  al- 
ways accompanied  with  a  more  or  less  considerable  laceration 
of  the  ligauients,  and  are  followed  by  an  inflammatory  swelling 
di^cult  to  subdue;  hence  the  full  use  of  the  wrist  is  not  re- 
covered for  a  considerable  time.  When  the  bones  are  reduced, 
the  remainder  of  the  treatment  is  the  same  as  in  cases  of  sprains 
refrigt  rents  and  repellents  are  to  be  first  used,  amd  then  emol- 
lients and  resolvents.     The  patient  must  not  fatigue  the  hand 


OF    THE    BONES    OF    THE    CARPUS,    &C.  26 1 

much,  even  for  some  time  after  complete  recovery,  lest  he  ex- 
cite inflammation,  and  lay  the  foundation  of  a  white  swelling. 
Luxations  inwards,  and  those  outwards,  are  never  complete. 
The  laceration  of  the  ligaments,  a  tumour  at  the  internal  or  ex- 
ternal side  of  the  joint,  and  distortion  of  the  hand,  are  the 
concomitant  symptoms  of  these  luxations,  and  mark  them  out 
sufficiently.  They  are  reduced  by  making  gentle  extension, 
and  causing  the  two  surfaces  of  the  joint  to  slide  on  one  ano- 
ther in  a  dire£l:ion  contrary  to  what  they  took  in  luxating,  and 
by  bringing  the  hand  into  its  natural  situation.  The  danger  of 
these  luxations  depends  less  on  the  dislocation  than  on  the 
Straining  and  laceration  of  the  soft  parts,  which  are  always  fol- 
lowed by  more  or  less  tumefa<^ion,  a  symptom  difficult  to  sub- 
due, and  often  the  cause  of  anchylosis,  or  even  of  caries. 


SECTION   II. 


Of  Luxations  of  the  Bones  of  the  Carpus  and  Metacarpus 

The  motions  of  the  bones  of  the  carpus  in  their  articulations 
with  one  another  are  so  limited,  and  their  connexion  is  so 
strong,  that  a  dislocation  of  them  appears  entirely  impossible. 
However,  the  head  of  the  os  magnum,  which  is  received  in  a 
deep  cavity  formed  for  it  by  the  scaphoides  and  semilunaris, 
jcnay  escape  from  this  cavity,  be  luxated  backwards  by  too  great 
a  flexion  of  the  bones  of  the  first  range  on  those  of  the  second, 
and  form  a  tumour  on  the  superior  part  of  the  back  of  the 
hand.  I  have  lately  seen  a  remarkable  case  of  this  luxation. 
Mrs.  B.  in  a  labour  pain,  seized  violently  the  edge  of  her  mat- 
tress, and  squeezed  it  forcibly,  turning  her  wrist  forwards; 
she  instantly  heard  a  slight  crack,  and  felt  some  pain,  to  which 
her  other  sufferings  did  not  allow  her  to  attend.  Fifteen  days 
afterwards,  happily  delivered,  and  recovered  by  the  care  of 
Professor  Baudelocque,  she  shewed  her  left  hand  to  this  cele- 
brated accoucheur,  and  expressed  her  disquietude  about  the 
tumour  which  appeared  on  it,  especially  when  much  bent.  I 
was  called  to  visit  this  lady.  I  found  that  this  hard  circum- 
scribed tumour,  which  disappeared  almost  totally  by  extending 
the  hand,  was  formed  by  the  head  of  the  os  magnum  luxated 
backwards;  I  replaced  it  entirely  by  extending  the  hand,  and 


262  OF    LUXATIONS    OF    TH^    FINGERS. 

making  gentle  pressure  on  it.  As  the  afFe£tion  did  not  impede 
the  motion  of  the  part,  as  the  tumour  disappeared  on  extend- 
ing the  hand,  and  as  it  would  have  been  even  little  apparent 
in  any  state  of  the  hand,  had  Mrs.  B.  been  more  in  flesh,  I 
advised  her  not  to  be  uneasy  about  it,  and  to  apply  no  re- 
medy to  it.  Chopart  observed  a  similar  dislocation  in  a  butcher. 
Professor  Boyer's  practice  has  presented  him  also  a  case  of  it. 

As  to  the  bones  of  the  metacarpus,  they  are  connected  so 
closely  and  strongly,  and  support  one  another  so  firmly  in  ef- 
forts made  against  the  palm  of  the  hand,  that  they  are  never 
luxated.  The  ligaments  of  their  articulations  may,  however, 
be  overstretched  and  torn,  and  a  painful  diastasis  produced, 
which  will  require  the  use  of  emollients  and  resolvents,  with 
immobility  of  the  hand  as  long  as  the  affe£lion  continues. 

Notwithstanding  the  mobility  of  the  articulation  of  the  tra- 
pezium with  the  first  bone  of  the  metacarpus,  the  latter  is  lux- 
ated but  very  rarely.  Efforts  made  on  the  thumb,  which  is 
supported  by  this  bone,  would  produce  rather  a  luxation  of  the 
first  phalanx,  than  that  of  the  metacarpal  bone.  The  second 
and  third  bones  are  so  firmly  articulated  with  one  another,  and 
with  the  bones  of  the  second  row  of  the  carpus,  that  they  are 
not  susceptible  of  any  luxation  whatever.  As  to  the  fourth  and 
fifth,  a  little  more  moveable,  and  supported  by  the  os  unci- 
forme,  their  articulations  are  more  susceptible  of  sprains  than 
true  luxations. 


SECTION    III. 


Of  Luxations  of  the  Fingers. 

The  first  phalanges  may  be  luxated  backwards  at  their  aiw 
ticulations  with  the  bones  of  the  metacarpus.  A  luxation  of 
them  forwards  would  be  very  difiicult,  if  not  altogether  impos- 
sible>  on  account  of  the  disposition  of  the  articulating  surfaces 
of  the  metacarpal  bones,  which  are  much  elongated  forwards, 
and  allow  a  great  extent  of  motion  to  the  phalanges  in  this 
dire<ftion,  without  losing  contact  with  them;  and  on  account 
of  the  resistance  made  by  the  palm  of  the  hand,  which  would 
restrain  the  flexion  carried  beyond  what  the  inclination  of  the 
articulating  surfaces  would  admit  of.     Luxations  inwards  can 


OF    LUXATIONS    OF    THE    SINGERS.  iS^ 

take  place  only  In  the  first  phalanges  of  the  thumb  and  little 
finger  J  as  to  that  outwards,  the  first  phalanx  of  the  thumb  alone 
is  susceptible  of  it.  This  phalanx  is  also  the  most  exposed  to 
luxations  backwards.  When  a  violent  effort  is  made  on  the 
thumb  from  before  backwards,  its  first  phalanx  slips  behind 
the  head  of  the  first  metacarpal  bone,  and  remains  extended, 
while  the  second  is  bent,  its  flexor-muscle  being  thrown  into 
aftion  by  the  irritation.  The  distortion  of  the  thumb,  the  im- 
possibility of  bending  the  first  phalanx,  and  the  pain,  render 
this  luxation  sufiiciently  evident. 

The  more  violent  the  effort  necessary  to  produce  these  lux- 
ations, the  more  grievous  are  their  consequences.  In  some  per- 
sons in  whom  the  ligaments  are  excessively  relaxed,  they  pro- 
duce nojnconvenience.  In  such,  the  first  phalanx  of  the  thumb 
may  be  luxated  at  will  j  but  then  it  is  as  easily  reduced  as  dis- 
placed. 

These  luxations  should  be  quickly  reduced,  for,  at  the  end 
of  eight  or  ten  days,  they  are  irreducible.  Desault,  in  a  case  of 
this  kind,  proposed  making  an  incision  behind  the  superior 
extremity  of  the  phalanx,  and  by  means  of  it  to  introduce  a 
spatula,  in  order  to  push  the  phalanx  into  its  place ;  but  the 
patient,  frightened  at  the  operation,  would  not  submit  to  it. 
Citizen  Boyer  has  also  observed  in  a  hair-dresser,  a  luxation 
backwards  irreducible  from  having  continued  too  long. 

The  redudtion  is  not  as  easy  as  one  might  imagine.  The  num- 
ber and  force  of  the  muscles  which  are  inserted  into  the  first 
phalanx  of  the  thumb,  and  the  little  hold  we  can  take  of  this 
part  in  order  to  make  extension,  render  the  reduction  difficult. 
Luxations  of  the  first  phalanges  of  the  thumb  and  little  finger 
inwards,  that  of  the  thumb  outwards,  and  luxations  of  the  first 
phalanges  of  the  other  fingers  backwards,  are  all  reduced  by 
making  extension  on  the  inferior  extremity  of  the  affedled  fin- 
ger, round  which  a  fillet  is  to  be  passed  if  there  be  occasion  for 
much  force.  The  wrist  is  fixed  by  an  assistant,  who  makes 
counter-extension,  and  the  surgeon  replaces  the  bone.  The 
first  and  second  phalanges  are  also  susceptible  of  luxation  back- 
wards, which  only  difiers  from  the  former  by  being  more  easily 
reduced.  After  the  reduftion  is  accomplished,  a  roller  is  put 
round  the  finger  to  prevent  a  return  of  the  luxation. 


l64 


CHAPTER  XII. 


OF  LUXATIONS  OF  THE  FEMUR. 

THE  articulation  of  the  femur  with  the  bones  of  the  pelvis 
is  so  strong  and  well  secured,  that  luxations  of  it  are  not 
frequent;  thus  they  are  much  rarer  than  those  of  the  humerus, 
yet  they  are  described  by  all  authors,  ancient  and  modern* 
But  I  am  disposed  to  think  that  pradlitioners  have  often  con- 
founded primary  luxations  of  the  femur  with  fradtures  of  the 
neck  of  this  bone,  which  are  much  more  common. 

These  luxations  may  take  place  upwards  and  outwards  on  the 
external  face  of  the  os  ilium,  upwards  and  forwards  on  the 
body  of  the  os  pubis,  downwards  and  inwards  on  the  foramen 
ovale,  and  downwards  and  outwards  on  the  os  ischium.  Hence 
their  division,  generally  admitted,  into  four  well-marked  spe* 
cies. 

Luxation  upwards  and  outwards,  and  that  downwards  and 
inwards,  are  the  most  frequent ;  and  it  is  not  easy  to  ascertain 
which  of  these  two  takes  place  oftenest.  No  anatomical  reason 
can  be  given  for  the  frequency  of  the  first*  ;  the  edge  of  the 
acetabulum  projects  more  at  the  superior  and  exterior  parts 
than  at  any  other;  the  orbicular  ligament,  which  is  very  thick 
at  this  place,  nnd  the  interior  ligament  of  the  articulation, 
which  must  be  previously  ruptured,  oppose  the  dislocation  in 
this  diredlion.  There  is  little,  on  the  contrary,  to  oppose  the 
luxation  downwards  on  the  foramen  ovale.  The  inferior  and 
internal  part  of  the  circumference  of  the  cavity,  the  place  by 
which  the  bone  escapes  in  this  species  of  luxation,  presents  a 
deep  notch  formed  into  a  hole  by  a  ligament,  under  which  the 
vessels  of  the  articulation  enter.  The  orbicular  ligament  is  thin- 
ner here  than  at  any  other  place;  the  motion  of  abduftion,  in 
which  this  luxation  takes  place,  is  more  extensive  than  that  of 

*  Except  the  disposition  of  the  head  of  the  femur,  the  articulating  part 
of  which,  covered  with  cartilage,  is  cgjitinued  farther  upwards  and  out- 
wards, than  downwards  and  inwards. 


OP    LUXATIONS    OF    THE    FEMUR.  265 

addu£l'ion;  and  lastly,  the  round  ligament  within  the  articular 
tion  does  not  oppose  if,  as  it  may  take  place  without  its  being 
ruptured. 

Luxation  upwards  and  forwards  is  very  rare ;  that  down- 
wards and  backwards  is  still  more  so;  and,  perhaps  as  shall  be 
observed  farther  on,  never  occurs  but  secondarily. 

When,  by  a  fail  from  a  place  more  or  less  elevated,  on  the 
soles  of  the  feet,  or  on  the  knees,  the  thigh  is  pushed  for- 
wards and  inwards,  the  head  of  the  femur,  forced  towards  the 
superior  and  external  part  of  the  acetabulum,  breaks  the  inter- 
nal and  orbicular  ligaments,  escapes  through  the  laceration  in 
the  latter,  and  ascends  on  the  external  face  of  the  os  ilium  ; 
but  as  the  part  of  the  os  ilium  immediately  above  and  at  the 
external  side  of  the  cavity,  is  very  convex,  the  head  of  the 
femur  soon  abandons  its  first  position,  and  slides  backwards 
and  upwards  into  the  external  fossa  of  the  os  ilium,  following 
the  inclination  of  the  plane  towards  this  fossa,  and  obeying 
the  action  of  the  glutJei  muscles  which  draws  it  in  this  direc- 
tion. The  head  of  the  femur,  in  ascending  thus  on  the  exter- 
nal face  of  the  os  ilium,  pushes  upwards  the  glutseus  minimus, 
which  forms  a  sort  of  cap  for  it ;  and  the  glutseus  maximus 
and  medius  are  relaxed  by  the  approximation  of  the  points 
into  which  they  are  inserted.  The  pyriformis  is  nearly  in  its 
natural  state,  the  gemini,  obturatores,  and  quadratus  femoris, 
are  a  little  elongated.  The  psoas  magnus  and  iliacus  internus 
are  relaxed,  as  are  also  the  other  muscles  inserted  into  the  tro- 
chanter minor.  If  to  this  description  it  be  added,  that  the  or- 
bicular ligament,  torn  at  its  superior  part,  is  stretched  over 
the  acetabulum  and  covers  it,  an  exact  idea  may  be  formed  of 
the  change  occasioned  in  the  surrounding  parts  by  this  luxation 
of  the  femur. 

The  affected  thigh  is  shorter  than  the  sound  one  :  it  is  a  lit- 
tle bent,  and  carried  inwards.  The  knee  inclines  more  for- 
wards and  inwards  than  the  opposite  one ;  the  leg  and  thigh 
are  turned  inwards,  and  the  foot  points  in  this  direction.  The 
trochanter  major  is  brought  nearer  the  anterior  and  superior 
spinous  process  of  the  os  ilium,  and  is  at  the  same  time  ele- 
vated and  carried  a  little  forwards ;  the  latter  circumstance 
may  be  considered  as  the  necessary  consequence  of  the  rotation 
inwards  of  the  thigh.  The  natural  length  of  the  Umb  cannot 
be  restored  without  reducing  the  luxation  ;  the  foot  cannot  be 
turned  outwards,  and  any  attempt  to  do  so  causes  pain ;  but 
the  inclination  of  the  foot  Inwards  may  be  increased.  If  the  pa- 
34 


0.66  OF    LUXATIONS    OF    THE    FEMUR. 

tient  endeavours  to  walk,  he  extends  the  foot  to  put  the  top  of 
of  it  on  the  ground  ;  and  though  the  heel  is  raised,  he  is  still 
lame ;  for  the  diseased  limb  remains  always  shorter  than  the 
other,  and  the  pain  occasioned  by  the  attempt  to  walk  ren- 
ders progression  still  more  difficult. 

Luxation  of  the  femur  upwards  and  outwards  has  nothing 
in  common  with  the  fracture  of  the  neck  of  this  bone  but  the 
shortness  of  the  limb.  The  easy  rotation  of  the  member 
outwards  and  inwards,  &c.  &c.  preclude  all  possibility  of  con- 
founding them,  unless  the  surgeon  be  remarkably  inattentive. 

It  is  difficult  to  assign  the  cause  of  the  foot  and  remainder  of 
the  limb  being  turned  inwards  in  this  luxation.  It  may  be  esta- 
blished as  a  general  rule,  that  luxated  members  always  take  a 
direftion  determined  by  the  elongation  of  the  muscles  of  the 
side  opposite  that  to  which  the  luxated  bone  is  carried  :  thus  in 
luxation  of  the  arm  downwards  and  inwards,  the  deltoides  and 
infraspinatus  muscles,  lengthened  by  the  separation  of  their 
points  of  insertion,  move  the  elbow  out  from  the  body,  and 
give  the  arm  an  oblique  direction.  In  this  case,  the  obtura- 
tores,  gemini,  and  quadratus  femoris,  being  elongated,  the 
point  of  the  foot  ought  to  be  turned  outwards.  This  pheno- 
menon depends  perhaps  on  the  external  portion  of  the  orbicu- 
lar ligament  which  comes  from  the  anterior  and  inferior  spine 
of  the  OS  ilium  ;  this  portion,  which  is  very  thick,  being 
elongated  in  the  luxation  outwards,  draws  the  great  trochanter, 
forwards,  and  consequently  turns  inwards  the  entire  limb. 

The  difficulty  of  reducing  luxations  of  the  thigh,  from  the 
strength  and  number  of  its  muscles,  renders  every  dislocation 
of  which  it  is  susceptible  very  distressing.  The  laceration  and 
injury  done  to  the  soft  parts  are  nearly  as  considerable  as  io 
dislocations  of  the  ginglymoidal  articulations. 

To  effect  the  reduction,  the  patient  is  extended  on  a  table 
firmly  fixed,  and  covered  with  a  mattress  which  is  to  be  tied 
to  it  j  a  sheet  folded  longitudinally  is  applied  to  the  groin  of  the 
sound  side,  in  order  to  make  counter-extension.  The  middle 
part  is  applied  against  the  superior  and  internal  part  of  the 
thigh,  and  the  two  ends  passed  before  and  behind  the  pelvis, 
cross  on  the  hip,  and  are  held  by  a  sufficient  number  of  assist- 
ants. By  this  means  the  trunk  is  fixed,  but  there  is  nothing 
to  prevent  the  pelvis  from  yielding  to  the  extending  force.  To 
answer  this  purpose,  another  sheet  folded  in  a  similar  mannftr 
is  placed  transversely  on  the  spine  of  the  os  iliui'O,  and  its  ends 
are  brought  horizontally  before  and  behind  the  abdomen  to- 
wards the  hip  of  the  opposite  side,  where  they  are  held  by  as- 


OF    LtrXATtONS    OF    THE    FEMUR.  267 

sistants.  This  apparatus,  similar  to  that  placed  on  the  point 
of  the  shoulder  in  a  luxation  of  the  arm,  answers  the  same 
purposes,  as  it  presses  only  on  the  superior  part  of  the  glutaeus 
maximus  and  medius,  and  does  not  stimulate  them  to  contraifl. 
The  extending  force  is  to  be  applied  to  the  inferior  part  of  the 
leg,  in  order  to  have  it  as  far  as  possible  from  the  parts  which 
resist  the  return  of  the  head  of  the  femur.  The  number  of 
assistants  for  making  extension  and  counter  extension  is  to  be 
proportioned  to  the  exigencies  of  the  circumstances  and  the 
power  of  the  muscles.  The  surgeon,  placed  at  the  external 
side  of  the  limb,  presses  on  the  great  trochanter,  and  when 
the  head  of  the  bone  has  been  brought  on  a  level  with  the 
acetabulum,  he  endeavours  to  force  it  into  it. 

The  disappearance  of  all  the  symptoms,  and  especially  the 
noise  made  by  the  head  of  the  femur  on  re-entering  its  cavity, 
indicate  the  success  of  the  operation.  This  success  is  seldom 
obtained  without  having  previously  made  several  fruitless  en- 
deavours, whether  from  not  employing  sufficient  force  to  make 
extension  and  counter-extension,  or  from  a  spasmodic  contrac- 
tion of  the  muscles  obstinately  resisting  the  redudlion. 

When  the  bone  is  reduced,  it  is  prevented  from  leaving  its 
place  by  bringing  the  thighs  together  by  means  of  a  bandage 
placed  above  the  knees.  In  the  generality  of  cases  it  will  be 
adviseable  to  take  some  blood  from  the  patient,  and  confine 
him  for  a  few  days  after  the  accident  to  a  very  low  diet ;  and 
in  all  cases  the  hip  is  to  be  covered  with  emollient  and  resol- 
vent applications,  which  may  be  kept  on  by  means  of  the  spica 
bandage  for  the  groin.  This  bandage  is  well  adapted  to  this 
use,  but  is  not  at  all  fit  for  keeping  the  luxated  bone  in  its  pro- 
per place,  as  its  a£lion  is  made  too  near  the  centre  of  motion. 
The  patient  should  be  particularly  diredled  not  to  walk  too 
soon,  nor  at  any  time  to  fatigue  too  much  the  afFefted  joint. 
It  remains  always  weaker  than  the  other ;  the  round  ligament 
never  unites  completely,  if  even  its  reunion  be  possible.  When 
the  limb  has  not  been  left  at  rest  for  a  sufficient  length  of  time, 
(twenty  days  at  least),  the  pain  can  never  be  said  to  have  en- 
tirely disappeared  ;  it  is  revived  by  the  slightest  effi^rt,  and  at 
length  becomes  permanent.  The  patient,  however,  does  not 
complain  much  of  the  pain,  but  it  is  more  than  probable  that 
it  is  occasioned  by  a  swelling  of  the  cartilages  and  synovial 
glands  of  the  articulation,  the  direful  forerunner  of  spontane- 
ous luxation  of  the  femur,  and  of  caries  of  the  bones  forming 
the  acetabulum; 


268  OF   LUXATIONS    OF    THE    FEMUR. 

Luxation  of  the  thigh  downwards  and  inwards,  or  into  ikt 
foramen  ovale,  is  nearly  as  frequent  as  that  just  described;  it  is 
favoured,  as  we  have  said,  by  the  great  extent  of  the  motion 
of  abduftion  of  the  thigh;  by  the  notch  at  the  inferior  and  in- 
ternal part  of  the  acetabulum;  by  the  weakness  of  the  orbicu- 
lar ligament  at  this  side ;  and  lastly  by  the  situation  of  the  round 
ligament,  the  rupture  of  which  is  not  a  necessary  consequence 
of  it.  It  is  occasioned  by  a  fall  on  the  feet  or  knees  conside- 
rably separated  from  one  another.  The  head  of  the  femur 
slides  from  without  inwards  on  the  bottom  of  the  acetabulum, 
and  comes  against  the  inferior  and  internal  portion  of  the  or- 
bicular ligament,  which  it  lacerates,  and  passes  on  to  the  fora- 
men ovale  between  the  ligament  and  the  obturator  externus. 

In  this  species  of  the  luxations  of  the  femur,  the  state  of  the 
soft  parts  surrounding  the  articulation  is  as  follows  :  the  glutaei, 
gemini,  obturatores,  quadratus  femoris,  psoas  magnus,  and 
iliacus  internus,  are  elongated  by  the  separation  of  their  points 
of  insertion.  The  rotation  of  the  limb  outwards  is  produced 
by  the  elongation  of  these  muscles.  The  adducSlors,  elongated, 
form  at  the  interior  part  of  the  thigh  a  tense  cord,  which  is 
felt  from  the  pubis  to  below  the  middle  of  the  thigh. 

The  afFedted  thigh  is  longer  than  the  sound  one ;  the  head 
of  the  femur  being  placed  lower  than  the  acetabulum,  the 
great  trochanter  is  removed  to  a  greater  distance  from  the  an- 
terior and  superior  spinous  process  of  the  os  ilium,  and  the 
thigh  is  flattened  in  consequence  of  the  elongation  of  the  mus- 
cles. The  adductors,  extended  obliquely  from  the  pubis  to 
the  femur,  form  a  cord  which  elevates  the  skin  of  the  inter- 
nal part  of  the  thigh.  A  hard  round  tumour  is  felt  at  the  in- 
ner and  superior  part  of  the  thigh,  formed  by  the  head  of  the 
femur,  which  elevates  the  soft  parts  situated  before  the  foramen 
ovale.  The  leg  is  slightly  bent ;  the  knee  and  foot  turned 
outwards,  cannot  be  brought  back  to  their  proper  direction.  If 
the  patient  attempt  to  walk  a  few  steps,  he  makes  a  semicircu- 
lar motion  with  the  foot,  and  places  at  once  the  entire  sole  on 
the  ground;  and  though  he  keep  the  knee  bent,  still  the  limb 
is  too  long,  and  occasions  lameness.  The  mode  of  progression 
of  persons  whose  thigh  is  luxated  in  this  direction  may  be  com- 
pared to  that  of  a  mower  :  the  elongated  extremity,  like  the 
leg  which  the  mower  keeps  forwards,  describes  a  semicircular 
motion  outwards. 

All  these  symptoms  taken  together  form  a  combination  too 
striking  to  admit  of  error  in  our  diagnosis,  or  to  allow  us  to 


OF    LUXATIONS    OF    THE    FEMUR.  269 

confound  this  luxation  with  any  other,  or  even  with  fracture 
of  the  neck  of  the  femur. 

The  prognosis  is  somewhat  less  unfavourable  in  this  than  in 
luxation  upwards  and  outwards.  The  muscles,  which  might 
oppose  the  reduction,  being  all  elongated  by  the  very  circum- 
stance of  the  luxation  itself,  render  the  reducStion  easier;  besides, 
the  contusion  of  the  soft  parts  is  less  considerable,  and  the 
round  ligament  is  stretched,  but  not  broken.  It  is  reduced  in 
the  same  manner  as  the  other,  except  that  the  extension  is  to 
be  made  at  first  downwards  and  outwards,  before  bringing  the 
limb  to  its  natural  direction. 

Luxation  upwards  and  forwards  is  much  rarer  than  the  pre- 
ceding, and  more  than  one  pra6lioner  has  described  it  rather 
as  possible  than  as  having  absolutely  taken  place.  It  has  been 
also  called  luxation  on  the  pubis,  though  it  may  be  reasonably 
presumed  that  the  head  of  the  femur  is  removed  so  f?.r  from 
the  acetabulum  but  in  very  few  cases,  and  that  it  only  advances 
near  the  ilio-pe£tinseal  eminence.  Desault  met  a  luxation  of 
thii  kind  in  a  porter  of  the  flour-market:  his  foot  slipped,  and 
the  leg  and  thigh  were  carried  backwards,  whilst  a  heavy  bur- 
den was  placed  on  his  shoulders.  His  body  was  bent  back- 
wards, and  the  head  of  the  femur,  directed  forwards  and  up- 
wards, burst  its  capsule  and  triangular  ligament,  and  passed 
under  the  crural  arch  into  the  fold  of  the  groin,  where  it  was 
easily  felt  through  the  integuments. 

The  whole  extremity  is  turned  outwards  in  this  luxation:  it 
is  also  shortened.  The  great  trochanter,  brought  nearer  the 
anterior  and  superior  spinous  process  of  the  os  ilium,  is  placed 
before  that  eminence;  that  part  into  which  the  psoas  and  ilia-' 
cus  muscles  are  inserted  is  raised  up,  and  a  tumour  is  formed 
by  the  head  of  the  femur  in  the  fold  of  the  groin,  which  com- 
presses more  or  less  the  crural  nerves  placed  at  the  external  side 
of  the  vessels  of  this  name,  and  occasions  dull  pains,  with 
numbfless  and  even  paralysis,  when  the  contusion  has  been  very 
great;  the  knee,  turned  outwards,  is  also  carried  backwards^ 
This  symptom  is  particularly  remarkable  shortly  after  the  acci- 
dent has  taken  place;  for  if  the  dislocation  has  continued  some 
days,  the  thigh  may  reassume  its  natural  dlrecTtion,  and  per- 
form even  gentle  rotatory  motions  inwards,  the  direction  out- 
wards still  continuing.  It  is  proper  to  remark,  with  respedt  to 
the  tumour  formed  by  the  head  of  the  femur  in  the  groin,  that 
the  psoas  and  iliaeus  muscles  may,  in  fraiftures  of  the  femur 
immediately  under  the  little  trochanter,  bring  forwards  the  su- 


ayo  or  luxations  of  the  femur. 

perior  portion  of  this  bone,  cause  it  to  project  in  the  groin,  an^ 
form  an  eminence  there  which  might  impose  on  us,  if  we  were 
not  apprized  of  the  possibiUty  of  such  an  event  taking  place. 

This  luxation  is  particularly  dangerous,  as  it  requires  a  com- 
bination of  violent  efforts  to  produce  it,  and  as  it  necessarily 
must  be  accompanied  with  great  contusion  and  lacerations. 
Nevertheless,  in  the  case  treated  by  Desault,  the  reduftion^ 
though  difficult,  was  not  followed  by  any  serious  accident;  and 
the  patient,  at  the  end  of  fifteen  days,  had  almost  entirely  re- 
covered the  strength  and  use  of  his  limb. 

The  process  for  reducing  it  does  not  differ  from  that  pointed 
out  for  the  others. 

Luxation  of  the  femur  downwards  and  backwards  may,  like 
that  of  the  humerus  inwards  and  forwards,  be  either  primary 
or  secondary.  It  is  primary,  when,  in  consequence  of  some 
effort,  the  head  of  the  femur  is  forced  from  the  acetabulum  at 
its  inferior  and  posterior  part,  and  is  placed  at  the  jun£\ion  of 
the  OS  ilium  and  ischium;  it  is  secondary,  when  it  succeeds  to 
the  luxation  upwards  and  outwards,  the  head  of  the  fenuir, 
which  was  placed  at  first  in  the  external  iliac  fossa  sliding  down- 
tvards  and  backwards,  its  passage  in  this  direcStion  being  fa- 
voured by  the  bending  of  the  thigh  on  the  pelvis. 

In  these  two  cases,  the  head  of  the  femur  rests  against  that 
part  of  the  ossa  innominata  where  the  os  ilium  and  ischium 
join.  The  muscles  which  cover  the  posterior  part  of  the  arti- 
culation, such  as  the  pyriformis,  gemini,  obturatores,  and  qua- 
dratus  femoris,  are  raised  up  and  stretched;  the  psoas  magnus 
and  illiacus  internus  are  in  a  great  state  of  tension,  and  this 
explains  the  turning  of  the  limb  outwards.  When  this  luxa- 
tion is  primary,  the  extremity  is  lengthened;  a  hard  tumour  is 
felt  at  the  posterior  and  inferior  part  of  the  thigh;  the  great 
trochanter,  by' descending,  is  removed  farther  from  the  spine 
of  the  OS  ilium,  and  the  knee  and  sole  of  the  foot  are  turned 
outwards;  but  if  it  be  secondary,  the  thigh  is  much  bent  Against 
the  pelvis;  the  knee  and  sole  of  the  foot  are  turned  inwards, 
because  the  primary  luxation  has  been  upwards  and  outwards. 
Secondary  luxation  in  this  dire(5lion  is  much  more  frequent 
than  the  primary:  in  reducing  it,  the  same  rules  are  to  be  ob- 
served as  in  other  species  of  luxations. 

Whatever  may  be  the  species  of  luxation,  we  should  always 
be  certain  that  it  is  perfectly  i-educcd  before  leaving  the  patient. 
To  ascertain  thi:;,  v/e  ought  to  move  the  thigh  in  various  di- 


OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR.       27  I 

reftlons,  taking  care  at  the  same   time  to  omit  that  motion 
which  might  reproduce  the  luxation. 

When  a  luxation  of  the  femur  upwards  and  outwards  has 
not  been  reduced,  the  thigh  remains  short,  and  becomes  shorter 
every  day,  until  the  head  of  the  femur  has  made  for  itself  a 
kind  of  articular  cavity  in  the  surface  of  the  external  iliac  fossa. 
The  acetabulum  lessens  in  size,  or  is  entirely  obliterated.  The 
glutaeus  minimus  is  emaciated,  and  serves  as  an  orbicular  liga- 
ment to  the  new  articulation.  The  head  of  the  femur  loses  its 
spherical  figure,  is  forced  backwards,  and  its  neck  becomes 
shorter;  the  person  is  lame,  and  walks  on  the  point  of  the 
foot.  If  the  luxation  is  downwards  and  inwards,  the  foramen 
ovale  becomes  the  new  articulating  cavity;  the  obturator  ex- 
ternus,  raised  and  pushed  inwards  by  the  head  of  the  femur, 
becomes  emaciated  and  ligamentous,  and  it  and  the  glutseus 
minimus  even  sometimes  ossify.  The  lameness  arises  in  this 
case  from  the  excess  of  length  of  the  diseased  limb,  which  al- 
ways dimmishes  in  size,  in  consequence  of  the  muscles  not 
being  sufficiently  exercised,  or  their  adtion  being  impeded. 


CHAPTER  XIII. 


OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR. 

IT  is  not,  perhaps,  without  transgressing  the  rules  of  noso- 
logy, that  these  afFe6lions,  which  arise  from  a  swelling  or 
caries  of  the  ends  of  the  bones,  have  been  ranked  among  the 
luxations  of  the  femur.  The  dislocation,  by  some  called  spon- 
taneous, by  others  secondary,  is  in  fa6l  but  the  symptom  of  a 
more  grievous  affedlion  which  always  precedes  it,  and  against 
which  our  treatment  should  be  principally  direfted.  The 
names  spontaneous  and  secondary  are  well  applied  to  it;  the 
first,  because  it  often  appears  to  come  of  itself  without  any 


272       or  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR. 

apparent  cause;  the  second,  because  it  is  the  consequence  of 
another  disease.  This  luxation,  though  much  more  common 
than  the  primary,  has  been  unknown  from  the  time  of  Hippo- 
crates, who  describes  it  by  the  name  of  disease  of  the  hips 
[morbus  coxarum)  in  two  of  his  Aphorisms,  to  that  of  J.  L. 
Petit;  who,  though  he  mistook  its  etiology,  has  nevertheless 
given  a  very  exatl  description  of  it  in  the  Memoirs  of  the  Aca- 
demy of  Sciences  for  the  year  1 722. 

Two  principal  varieties  of  secondary  luxations  are  pointed 
out.  In  the  one,  the  dislocation  is  occasioned  by  the  swelling 
of  the  cartilages  which  line  the  acetabulum  and  cover  the  head 
of  the  femur,  and  by  the  enlargement  of  the  cluster  of  glands 
in  the  interior  of  the  articulation,  and  which  have  been  a  long 
time  considered  as  destined  for  the  secretion  of  synovia.  In 
the  other,  it  arises  from  caries  of  the  circumference  of  the 
acetabulum  or  head  of  the  femur.  The  same  causes  may  occa- 
sion both  varieties;  they  are  either  external  or  internal. 

It  is  only  lately  that  surgeons  have  admitted  the  possibility  of 
secondary  luxation  of  the  femur  from  an  external  cause.  It 
■Was  generally  believed  that  it  could  be  produced  only  by  internal 
causes,  which,  in  fa6t,  are  the  most  frequent.  But  it  is  now 
clearly  ascertained,  that  contusion  of  the  cartilages  and  seba- 
ceous cluster  of  glands  of  the  joint  from  a  fall  on  the  feet, 
knees,  or  great  trochanter,  may  occasion  an  inflammation  and 
swelling  of  these  parts,  by  which  the  head  of  the  femur  will 
be  expelled  from  its  cavity. 

From  whatever  cause  it  arises,  its  most  ordinary  course  is 
this:  the  cartilages  and  sebaceous  glands,  irritated  by  the  ex- 
ternal violence,  or  by  a  scrofulous,  venereal,  or  scorbutic  taint, 
become  swelled;  the  cartilages  grow  soft,  and  degenerate  into 
a  greyish  substance  like  lard;  their  sensibility  increases,  and 
pains,  at  fli-st  dull  and  slight,  but  soon  acute  and  deep-seated, 
are  felt  in  the  diseased  joint.  The  head  of  the  femur,  pushed 
outwards  by  the  tumefaftion,  is  gradually  expelled  from  its 
cavity;  and  when  it  is  on  a  level  with  the  margin  of  the  ace- 
tabulum, it  is  drawn  upwards  and  outwards  on  the  external 
iliac  fossa,  by  the  gluta.'i  muscles,  and  but  very  rarely  down- 
wards and  inwards  on  the  foramen  magnum. 

If,  on  the  commencement  of  the  pains,  the  patient  be  ex- 
tended on  a  plane,  and  the  two  superior  and  anterior  spines 
of  the  ossa  iha  put  in  a  horizontal  hne,  it  will  be  found,  on  ex- 
amining the  affected  limb,  and  comparing  its  length  with  the 
sound  one,  that  it  is  somewhat  longer  than  the  other.     Thi<: 


OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR.         ayj 

elongation  increases  as  the  disease  advances,  and  is  never  so 
considerable  as  just  at  the  period  when  tlie  head  of  the  femur, 
on  a  level  with  the  edge  of  the  acetabulum,  is  about  to  pass 
over  it.  At  this  moment,  the  luxation  being  complete,  the 
head  of  the  femur  is  carried  away  by  the  adlion  of  the  mus- 
cles, and  the  limb  is  on  a  sudden  shortened  by  several  inches, 
except  in  the  very  rare  cases  in  which  the  bone  is  carried  down- 
wards and  inwards  on  the  foramen  ovale.  Sharp  pains  are  felt 
during  the  whole  course  of  the  disease;  they  may  arise  from 
the  affeftion  of  the  cartilages,  or  from  the  straining  of  the  or- 
bicular ligament.  They  have  this  very  striking  peculiarity,  that 
the  patient  complains  of  them  more  in  his  knee  than  in  his  hip, 
which  in  the  beginning  of  the  disease  might  lead  into  error. 

When  the  luxation  has  taken  place,  the  extremity  is  much 
shortened;  the  knee  and  point  of  the  foot  are  turned  inwards; 
the  great  trochanter  is  brought  nearer  the  spine  of  the  os  ilium; 
the  leg  is  bent;  in  fa^l,  all  the  symptoms  of  primary  luxation 
upwards  and  outwards  are  evident.  The  part  over  the  articu- 
lation swells  and  grows  round;  the  skin  is  soon  put  on  the 
stretch;  the  cellular  substance  swells  and  becomes  thick,  and 
the  tumour  puts  on  the  appearance  of  a  white  swelling;  in  some 
time,  a  softness  is  felt  at  different  points,  which  correspond  to 
so  many  abscesses;  these  burst,  and  their  openings  degenerate 
into  fistulge.  A  matter,  at  first  serous,  and  without  smell,  flows 
from  them;  but  its  qualities  are  soon  changed  by  the  conta£t 
of  the  air,  it  becomes  acrid,  irritating,  and  so  fetid,  that  the 
patient  and  those  near  him  can  scarcely  bear  the  smell  of  it : 
this  matter,  taken  into  the  system  by  absorption,  produces 
hedlic  fever,  marasmus,  colliquative  diarrhoea,  and  death. 

On  opening  the  body,  the  acetabulum  is  found  filled  by  its 
cartilage,  which  is  converted  into  a  soft  greyish  substance;  the 
sebaceous  glands  of  the  joint  are  also  swelled;  the  substance  of 
the  head  of  the  femur  is  altered,  and  its  shape  is  more  or  less 
changed  according  to  the  continuance  of  the  disease;  collections 
of  fetid  pus  are  found  in  the  interstices  of  the  muscles,  which 
are  discoloured  and  diminished  in  size;  and  the  os  innomina- 
tum  and  the  head  of  tiie  femur  are  frequently  carious. 

Such  is  the  exadl  history  of  the  first  variety  of  the  disease. 
The  progress  of  its  symptoms  is  somewhat  different  from  what 
is  observed  in  that  occasioned  by  caries;  different  appearances 
are  also  found  by  examination  after  death. 

In  the  second  variety,  the  pains  are  at  first  acute,  and  ac- 
companied with  swelling  of  the  hip:  considerable  abscesses  form 
^5 


274        OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR. 

in  this  part,  which  soon  burst;  a  matter,  at  first  inodorous, 
flows  abundantly  from  them,  but  in  a  little  time  it  is  vitiated 
by  the  contact  of  the  air,  and  the  openings  through  which  it 
passes  degenerate  into  fistulse. 

The  extremity,  which  was  not  sensibly  elongated,  becomes 
suddenly  shortened;*  the  head  of  the  femur  mounts  up  to  the 
external  iliac  fossa;  and  the  patient,  exhausted  by  the  copious 
suppurations  and  heclic  fever,  is  generally  carried  off.  On 
opening  the  joint,  it  is  found  that  the  edge  of  the  acetabulum 
has  been  destroyed  to  a  greater  or  less  degree  by  caries,  that 
the  cavity  has  t3een  nearly  effaced,  and  that  the  head  of  the 
femur  has  participated  in  the  disease. 

Both  the  varieties  which  we  have  just  described  may  be  in- 
duced even  in  a  person  enjoying  good  health  and  of  a  robust 
constitution,  by  a  quick  commotion  of  the  hip,  as  happens 
from  making  a  false  step,  by  a  fall  on  the  sole  of  the  feet,  on 
the  knees,  or  even  on  the  great  trochanter.  A  much  less  de- 
gree of  the  cause  will  produce  them,  if  the  patient  labour  un- 
der a  scrofulous,  venereal,  or  scorbutic  taint.  Scrofula  has 
been  so  frequently  the  cause  of  them,  that  it  has  been  supposed 
that  they  never  originated  from  any  other;  but  though  it  may 
be  the  most  frequent  cause,  still  cases  are  met  in  which  its  ex- 
istence could  not  be  suspected. 

It  may  be  objedled  by  those  who  believe  that  an  internal 
cause  is  absolutely  necessary  to  produce  the  disease,  that  the 
contusion  of  the  parts  about  the  joint  a6ls  only  as  an  occasional 
cause;  that  in  luxations  supposed  to  be  produced  by  a  fall  on 
the  great  trochanter,  the  injury,  by  determining  to  the  articu- 
lation, the  principle  which  vitiates  the  humours,  only  developes 
a  disease,  the  germ  of  which  was  contained  in  the  constitu- 
tion. 

J.  L.  Petit,  to  whom  we  are  indebted  for  the  first  accurate 
description  of  spontaneous  luxations  of  the  femur,  gives  the 
following  explanation  of  the  manner  in  which  they  take  place. 

"  By  a  fall  on  the  great  trochanter,  the  head  of  the  femur 
«'  is  violently  forced  against  the  sides  of  the  acetabulum;  and 
«  as  it  fills  exactly  the  cavity,  the  cartilages,  synoval  glands, 
"  and  round  ligaments,  must  receive   a  violent   commotion, 

*  Sometimes  a  caries  of  the  acetabulum  is  not  followed  by  luxation  of 
the  thigh,  Cifzen  Boyer  met  a  case  of  this  kind,  in  which  the  bottom  of 
the  cavity  onlv  was  afFtfted ;  tlie  ed^es  were  sound.  The  pus  made  its 
way  into  the  pelvis,  and  formed  an  abscess  in  the  gioin,  which  burst,  and 
left  a  fistulous  opening. 


OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR.        275 

«  which  will  occasion  obstruiStion,  inflammation,  and  a  depo- 
"  sition  of  matter:  the  synovia,  especially,  will  be  accumulated 
"  in  the  cavity  of  the  articulation;  the  capsule  will  be  distended 
**  by  it,  and  the  head  of  the  femur  gradually  expelled  until  it 
*'  is  entirely  luxated."  A  little  refledtion  will  shew  the  futility 
of  this  explanation:  admitting  even  that  the  secretion  of  syno- 
via was  increased  by  the  contusion,  without  any  increase  of  the 
absorption  of  it,  which  is  always  proportionate  to  its  secretion, 
and  that  this  fluid,  accumulated  between  the  neck  of  the  femur 
and  orbicular  ligament,  distended  this  latter,  still  a  dislocation 
would  not  take  place-,  a  dropsy  of  the  joint  would  be  the  con- 
sequence; for  the  liquid  could  not  expel  a  hard  resisting  body 
such  as  the  head  of  the  femur;  and  if  the  synovia  accumulated 
between  the  neck  of  the  femur  and  the  ligament  should  become 
thick,  it  would  tend  more  to  confine  the  bone  to  its  cavity  than 
to  displace  it.  Petit  knew  very  well  that  there  was  a  dispro- 
portion between  the  cavity  and  the  head  of  the  femur;  but  he 
was  mistaken  as  to  the  cause  of  this  disproportion,  and  as  to 
the  nature  of  the  substance  which  filled  the  cavity,  and  ex- 
pelled the  head  of  the  femur. 

The  prognosis  in  these  luxations  is  always' unfavourable;  it 
is,  however,  more  or  less  so,  according  to  the  age  and  consti- 
tution of  the  patient,  the  species  of  luxation,  its  continuance, 
and  the  cause  which  has  produced  it.  If  the  patient  be  young 
and  strong,  the  affedlion  recent,  and  accompanied  only  by  dull 
pains  and  inconsiderable  elongation  of  the  extremity,  if  there 
be  no  internal  taint,  and  if  the  cause  has  been  external,  the 
danger  is  much  less  than  if  the  patient  were  weak  and  exhaust- 
ed, the  disease  of  a  long  standing,  and  complicated  with  fistulx, 
&c.  &c.  The  prognosis  is  still  more  unfavourable  when  the 
luxation  takes  place  downwards  and  inwards,  the  head  of  the 
femur  being  placed  in  the  foramen  ovale,  and  the  extremity 
elongated.  This  species  of  luxation  is  fortunately  very  rare; 
the  lameness  in  it,  arising  from  the  elongation  of  the  limb,  is 
much  more  troublesome  than  that  arising  from  the  shortness 
of  it. 

The  principal  object  in  the  treatment  of  this  disease,  is  to 
prevent  the  spontaneous  luxation.  If  this  once  takes  place, 
the  danger  increases,  and  the  patient  may  consider  himself 
happy  if  the  head  of  the  femur  attaches  itself  to  the  portion  of 
the  OS  innominatum  against  which  it  bears,  or,  making  a  de- 
pression, forms  a  new  articulation.  Whenever,  in  consequence 
of  a  fall  on  the  feet,  knees,  or  great  trochanter,  a  person  feels, 


2^6        OF  SPONTANEOUS  LUXATIONS  OF  T^E  FEMUR. 

in  walking,  dull  pains  in  the  hip,  or  knee,  he  should  be  di- 
re(Sled  to  keep  the  limb  in  the  most  perfeft  repose,  until  they 
entirely  disappear.  Unfortunately,  there  are  few  patients  who 
will  confine  themselves  to  bed  for  a  complaint  apparently  so 
trifling,  or  submit  to  the  bleedings  and  strict  regimen  neeessary 
in  such  a  case.  At  the  same  time  that  means  such  as  these  are 
used,  emollients  and  resolvents  may  be  applied  to  the  hip. 

If  a  constitutional  taint  be  suspe<Sted,  our  attention  must  be 
diredted  to  it,  and  remedies  given  to  combat  it;  thus  we  exa- 
mine carefully  if  the  patient  labours  under  scrofula,  which  is 
characterized  by  the  softness  of  the  flesh,  discolouration  of  the 
skin,  swelling  of  the  upper  lip  and  sides  of  the  nostrils,  and 
enlargement  of  the  lymphatic  glands  in  some  parts  of  the  body, 
Sec.  Sec.  If  it  is  discovered  that  scrofula  has  produced  the  dis- 
ease without  the  co-operation  of  any  external  cause,  or  if  it  has 
given  the  predisposition,  and  a  fall  has  been  the  occasional 
cause,  tonics  must  be  administered,  such  as  good  wine,  bitter 
vegetable  infusions,  extra6l  of  bark,  &c.  an  issue  is  at  the  same 
time  to  be  established  at  some  distant  part,  to  prevent  the  de- 
termination of  the  humours  to  the  diseased  joint. 

A  large  blistei ,  applied  to  the  hip,  and  renewed  every  twen- 
ty-four hours,  produces  very  good  effects.  It  seems  to  deter- 
mine to  the  skin  the  irritation  that  has  taken  place  in  the  cavity 
of  the  joint,  and  the  abundant  serous  discharge  that  it  occa- 
sions, reduces  the  swelling  of  the  aftecSted  parts;  this  discharge 
should  be  kept  up  by  dressing  the  blistered  surface  with  an 
irritating  ointment.  I  have  seen  the  best  efFefts  from  a  blister 
applied  at  the  commencement  of  the  disease;  the  limb,  though 
somewhat  elongated,  was  restored  to  its  natural  length  by 
means  of  it. 

When  all  the  means  we  have  recommended,  with  perfedl 
rest,  the  use  of  blisters,  or  any  other  stimulant,  such  as  moxa, 
have  been  used  in  vain,  and  the  constitutional  taint  has  not 
been  subdued,  then  all  our  endeavours  should  tend  to  arrest 
the  progress  of  the  disease,  by  favouring  the  astachment  of  the 
head  of  the  femur  to  the  bones  of  the  pelvis.  For  this  purpose, 
perfedt  rest  of  the  limb  is  absolutely  necessary.  The  leg  and 
thigh  should  be  kept  extended;  without  this  precaution,  the 
patient,  from  his  natural  tendency  to  bend  the  limb,  in  order 
to  diminish  pam,  may  give  it  such  a  diredlion  that  it  will  be 
entirely  useless  to  him  after  his  recovery.  Le  Cat  cites  an  in- 
stance of  this  kind:  the  patient  having  escaped  the  dangers  of 
a  tedius  suppuration,  recovered,  but  the  femur  was  grown  to 


OF  SPONTANEOUS  LUXATIONS  OF  THE  FEMUR.         277 

the  OS  Innominatum,  so  as  to  form  a  right  angle  with  it:  thus, 
from  having  neglected  the  precaution  of  keeping  the  thigh  ex- 
tended, the  Hmb  was  rendered  not  only  useless  but  inconve- 
nient, and  the  person  enjoyed  but  very  imperfectly  the  advan- 
tages of  his  recovery. 

If,  notwithstanding  this  treatment,  abscesses  form  in  differ- 
ent points  of  the  tumour,  they  should  be  allowed  to  burst  of 
themselves,  in  order  that  the  admission  of  air  into  them  may 
be  retarded  as  much  as  possible;  and  if  it  be  deemed  neces- 
sary to  open  them,  the  incision  should  be  very  small,  and 
the  operation  deferred  as  long  as  possible. 

When  fistulous  openings  are  established,  they  should  be 
dressed  so  as  to  prevent  as  much  as  possible  the  admission  of 
air:  and  detergent  injedlions,  composed  of  barley-v/ater,  wine, 
and  honey,  a  solution  of  alcali,  or  any  other  liquid  more  or 
less  suited  to  the  sensibility  of  the  parts,  should  be  thrown  into 
the  fistulous  passages.  The  strength  is  to  be  supported,  and 
every  means  used  to  resist  the  exhaustion  occasioned  by  a  long 
and  copious  suppuration.  Mineral  waters,  extract  of  bark,  or 
syrup  of  bark  for  very  young  children,  and  a  nourishing  and 
invigorating  diet,  are  to  be  used  with  this  view.  If  the  sup- 
puration diminishes,  and  a  tendency  to  anchylosis  is  suspected, 
the  thigh  is  to  be  extended  as  much  as  the  pains  will  allow, 
and  kept  in  that  position  by  means  of  splints;  these  are  neces- 
sary on  account  of  the  patient's  constantly  endeavouring  to  bend 
his  thigh,  in  order  to  diminish  pain.  If  the  patient  is  young, 
the  epoch  of  puberty  is  often  favourable  to  him;  the  great  re- 
volution which  the  solids  and  fluids  undergo  at  this  period, 
proves  serviceable;  the  diseased  parts  exfoliate,  the  fistulae  dry 
up,  and  the  head  of  the  femur  attaches  itself  to  some  point  of 
the  OS  innominatum.  We  must  not  endeavour,  by  moving  the 
limb,  to  establish  a  new  articulation;  for,  by  disturbing  the 
head  of  the  femur,  the  irritation  might  be  renewed,  the  in- 
flammation increased,  and  the  anchylosis,  a  very  happy  termi- 
nation of  a  disease  in  which  the  life  of  the  patient  is  in  so  great 
danger,  prevented. 

Secondary  luxation  of  the  femur  downwards  and  inwards  on 
the  foramen  ovale,  is  less  frequent  than  that  upwards  and  out- 
wards; however,  many  cases  of  it  have  been  observed.  A 
young  man  felt  acute  pains  in  his  hip,  which  swelled  conside- 
rably in  a  very  short  time;  the  limb  became  elongated,  and 
was  turned  outwards;  the  knee  and  point  of  the  foot  were  in- 
clined in  the  same  direclion ;  the  leg  was  half  bent,  and  a  tu- 


278  Ot    LUXATIONS    Of    THE    PATELLA. 

mour  appeared  at  the  superior  and  internal  part  of  the  thigh 
in  the  perineum:  a  fluftuation  being  discovered  in  the  tumour, 
it  was  opened,  a  great  quantity  of  pus  escaped,  and  the  patient 
found  himself  relieved.  The  operator  was  applauded  for  his 
success,  but  the  pus,  at  first  benign,  soon  became  fetid:  the 
patient  was  exhausted  in  a  short  time,  and  died.  On  opening 
the  articulation.  Citizen  Boyer  found  the  acetabulum  destroyed 
by  caries,  which  had  committed  some  ravages  also  in  the  head 
of  the  femur. 

This  luxation  presents  the  same  symptoms  as  the  primary 
one  in  the  same  diredlion,  and  requires  the  same  treatment  as 
the  secondary  luxation  upwards  and  outwards.  When  the 
patients  recover  by  an  anchylosis  of  the  head  of  the  femur  with 
the  bones  of  the  pelvis,  the  lameness  arisuig  from  the  excess  of 
length  in  the  limb,  is  much  more  inconvenient  than  that  re- 
sulting from  its  shortness. 


CHAPTER  XIV. 


OF  LUXATIONS  OF  THE  PATELLA. 

THIS  bone,  placed  on  the  anterior  part  of  the  knee,  may 
be  luxated  upwards,  downwards,  outwards,  and  inwards, 
but  the  two  last  only,  properly  speals;ing,  merit  the  name  of 
luxation.  The  patella  in  fadl  cannot  be  luxated  downwards, 
and  descend  below  the  knee,  but  when  the  tendon  of  the  ex- 
tensor muscles  of  the  leg  is  broken  transversely:  in  which  case, 
the  tibia,  in  the  flexion  of  the  leg,  will  bring  down  the  patella, 
and  displace  it  in  the  same  manner  as  it  does  the  inferior  frac- 
tured portion  in  a  transverse  fracture  of  this  bone. 

Luxation  upwards  may  depend  on  a  rupture  of  the  inferior 
ligament  of  the  patella.  This  substance,  though  very  thick 
and  strong,  and  the  tendon  of  the  redtus  anterior  and  triceps 


OF    LUXATIONS    OF    THE    PATELLA.  279 

muscles,  of  which  it  is  only  a  continuation,  are  sometime  bro- 
ken transversely;  in  which  case,  the  muscles  carry  the  bone 
above  the  condyles  of  the  femur,  as  they  draw  up  the  superior 
piece  in  transverse  fraftures  of  it.  It  is  easily  seen,  that  the 
dislocations  of  the  patella,  in  these  two  cases,  is  only  the  effedl 
of  the  rupture  of  the  tendon  of  the  extensors  of  the  leg,  or  of 
the  ligament  which  unites  it  to  the  tibia. 

Luxations  inwards  or  outwards  take  place  when  the  patella 
is  violently  pushed  in  one  or  other  of  these  directions.  Great 
relaxation  of  the  inferior  ligament  of  the  patella  may  give  a 
predisposition  to  them.  Such  was  the  case  of  the  young  man, 
the  particulars  of  which  are  given  by  Citizen  Itard,  in  the 
Medical  Journal*,  the  relaxation  of  the  inferior  ligaments  was 
such,  that  the  patellae  were  luxated  outwards  by  the  slightest 
motion  of  the  knees. 

Of  the  lateral  luxations,  that  outwards  is  the  most  frequent. 
This  may  arise  from  the  internal  edge  of  the  patella  proje<fting 
more  than  the  external,  which  disposition  is  favourable  to  the 
a<n:ion  of  the  means  by  which  it  is  pushed  outwards,  and  from 
the  extent  of  the  articulating  surface  of  the  external  condyles 
of  the  femur,  which  allows  the  patella  to  slide  easily  on  it. 

The  external  condyle  of  the  femur  naturally  more  eminent 
anteriorly  than  the  internal  one,  may  be  depressed;  and  this 
depression,  whatever  may  be  the  cause  of  it,  favours  luxation 
in  this  diredlion.  I  have  seen  among  the  military  conscripts, 
three  cases  of  luxation  of  the  left  patella  outwards,  which  ap- 
peared to  depend  on  this  cause.  In  these  three  individuals, 
from  twenty  to  twenty-two  years  of  age,  the  patella  was  placed 
at  the  external  side  of  the  condyle,  without  having,  however, 
entirely  deserted  it;  its  anterior  face  was  turned  outwards,  its 
posterior  Inwards;  and  Its  Internal  edge  was  placed  anteriorly, 
and  projected  under  the  skin,  and  the  external  edge  was  di- 
rected backwards.  The  luxation  had  taken  place  in  all  during 
infancy.  Nothing  was  easier  than  to  replace  the  patella;  it 
was  done  by  relaxing  the  extensors  of  the  leg  and  bending  the 
thigh;  but,  unless  confined  to  its  place.  It  was  soon  again  dis- 
located; pulled  by  the  tendon  of  the  extensors,  and  Its  Inferior 
ligament,  which  had  contracted  an  oblique  direction,  It  sllded 
along  to  the  outer  side  of  the  knee. 

A  patient,  at  this  moment  In  the  hospital  Saint  Louis,  la-' 
hours  under  a  luxation  of  the  patella  outv/ards,  occasioned  by 
a  gun-shot  wound  in  the  neighbourhood  of  the  knee;  the  bone 
is  easily  reduced,  but  quickly  abandons  its  situation.     In  all 


2So       OF  LUXATIONS  OF  THE  PATELLA. 

siich  cases,  the  strength  of  the  articulation  of  the  knee  is  cott* 
siderably  diminished,  and  the  whole  extremity  is  reduced  in 
size. 

The  patella  is  easily  replaced,  but  difficultly  kept  in  its  situ-  • 
ation.  The  latter  purpose  might  be  accomplished,  by  applying 
a  bandage  about  the  joint,  the  pieces  of  which,  embracing  the 
sides  of  the  patella,  would  fix  it  on  the  anterior  part  of  the 
knee.  But  how  is  the  derangement  of  this  bandage  to  b6 
guarded  against  in  the  motions  of  the  knee,  and  what  is  to 
prevent  the  patella  from  passing  outwards?  None  of  the  per- 
sons just  mentioned  found  it  necessary  to  apply  for  surgical  aid; 
they  suffered  no  great  inconvenience  from  the  luxation,  and, 
as  it  exempted  them  from  military  service,  they  were  little 
anxious  to  have  it  remedied.  Indeed,  it  is  very  probable  that 
no  treatment  would  have  been  successful  in  such  cases. 

Luxations  outwards,  produced  by  external  violence,  may  be 
either  complete  or  incomplete  •,  it  is  seldom  complete,  as  it  re- 
quires a  very  considerable  violence  to  force  the  patella  entirely 
from  the  external  condyle  of  the  femur.  A  gentle  flexion  of 
the  knee  favours  it  very  much;  in  this  posture,  the  muscles,  the 
tendon  of  which  is  attached  to  the  patella,  are  relaxed,  and 
the  internal  edge  of  the  patella  projects,  and  is  favourably 
situated  for  the  a£lion  of  an  external  force  impelled  against  it. 

Valentin,  in  his  Criticisms  on  Surgery,  gives  a  case  of  lux* 
ation  of  this  kind.  The  Duke  de  Coigni,  in  galloping  in  the 
streets,  struck  his  knee 'against  the  wheel  of  a  carriage,  and 
luxated  the  patella  outwards.  He  was  carried  to  the  house  of 
Botentuit,  an  ignorant,  but  very  celebrated  bone-setter,  who 
made  many  endeavours  to  reduce  the  luxation,  but  which  were 
fruitless  on  account  of  the  position  in  which  he  had  placed  the 
limb;  he  kept  the  patient  on  his  feet,  and  made  him  extend 
his  leg  forcibly.  Valentin,  family  surgeon  to  the  Duke,  ar- 
rived, and  reduced  the  bone  "with  the  greatest  facility,  by 
placing  the  patient  on  a  bed,  extending  his  leg,  and  bending 
the  thigh  towards  the  pelvis. 

A  young  man,  in  running  in  a  room,  knocked  his  knee  against 
the  corner  of  a  trunk ;  the  blow  was  so  violent  as  to  luxate  the 
patella  outwards.  Citizen  Sabatier  was  consulted;  he  endea- 
voured to  reduce  it,  but  met  very  great  resistance.  Citizen 
Boyer  was  called  in:  by  using  much  force  he  efFe£led  the  re- 
duftion,  but  not  without  a  great  many  attempts. 

In  luxations  of  the  patella  outwards,  the  patient  feels  very 
acute  pain,  and  cannot   bend  his   leg;  the  knee  is  deformed. 


OF    LUXATIONS    OF    THE    PATELLA.  281 

the  pulley  (fflhe  condyles  of  the  femur  is  felt  through  the  skin, 
and  the  patella  forms  a  tumour  before  the  external  condyle  i 
instead  of  the  faces  of  the  patella  being  anteriorly  and  poste- 
riorly, the  anterior  is  become  the  external  and  the  posterior 
the  internal;  the  internal  edge  is  turned  more  forwards  than 
inwards,  and  the  external  is  become  nearly  the  posterior.  This 
position  of  the  patella  has  made  $om6  believe  that  it  might  be 
luxated  by  turning  half  over,  that  is,  by  placing  itself  per- 
pendicularly before  the  pulley  of  the  femur,  with  one  of  its 
edges,  now  become  posterior,  lodged  in  the  groove  of  the  pul- 
ley. Others  have  even  admitted  the  possibility  of  a  complete 
inversion,  in  which  the  posterior  face  of  the  patella  becomes 
the  anterior.  But  it  cannot  be  conceived,  that  the  extensors 
of  the  leg,  and  the  inferior  ligament  of  the  patella,  could  allow 
such  an  inversion  to  take  place  j  and  if  the  patella  was  only 
half  inverted,  and  one  of  its  edges  rested  on  the  pulley  of  the 
femur,  the  points  of  contact  would  be  so  few,  that  it  would 
slip  into  its  natural  position. 

The  symptoms  of  luxation  inwards  are  nearly  the  same  as 
those  just  described:  there  is  this  difference,  however,  that  the 
tumour  formed  by  the  patella  is  placed  internally.  In  both 
species,  if  called  in  before  the  swelling  takes  place,  we  can  feel 
through  the  skin  the  two  faces  of  the  patella;  the  posterior, 
excavated,  turned  towards  the  femur,  and  the  anterior  pro- 
jefting  under  the  skin. 

A  complete  luxation  cannot  take  place  without  great  relaxa- 
tion oi  the  inferior  ligament,  and  tendon  of  the  extensor  mus- 
cles, or  without  very  considerable  external  violence;  in  which 
case  the  luxation,  easy  to  reduce,  would  not  be  the  most  dan- 
gerous symptom. 

In  every  species  of  luxation  of  the  patella,  redu<Stioa  is  to  be 
eSe£ted  as  soon  as  possible.  It  is  done  by  placing  the  patient 
on  a  bed  with  the  leg  extended  and  the  thigh  bent.  In  this 
position  the  extensor  muscles  and  their  tendon,  as  well  as  the 
inferior  ligament  of  the  patella  are  relaxed;  and  this  bone  may 
be  moved  and  pushed  with  ease  in  the  direction  which  the  spe- 
cies of  luxation  requires.  We  think  it  is  always  possible  to  re- 
duce the  patella,  without  making  an  incision  Ln  the  integu- 
ments, and  introducing  a  spatula  under  the  bone.  This  ope- 
ration, though  recommended,  has  never  been  performed,  and 
never  could,  without  bringing  the  patient  into  great  danger. 

The  noise  made  by  the  bone  in  reassuming  its  place,  and  the 
disappearance  of  the  symptoms,  announce  the  reduction;  the 
36 


282  OF    LUXATIONS    OF    THE 

patient  can  now  bend  and  extend  the  leg.  The  mflammatory 
swelling,  which  generally  supervenes,  is  to  be  subdued  by  bleed- 
ings and  topical  applications.  This  treatment,  with  a  few  days 
rest,  will  be  sufficient;  after  some  time  the  knee  is  to  be  moved 
gently,  to  prevent  a  stiffness  of  the  joint,  which,  without  this 
precaution,  is  very  likely  to  take  place. 


CHAPTER  XV. 


OF  LUXATIONS  OF  THE  BONES  OF  THE  LEG. 

THE  tibia,  at  its  articulation  with  the  condyles  of  the 
femur,  may  be  luAated  in  four  different  diredlions;  viz. 
anteriorly,  posteriorly,  and  laterally  to  either  side  of  the  knee. 
The  luxation  backwards  is  always  incomplete*,  it  could  not  be 
otherwise  without  a  very  great  laceration  of  the  soft  parts.  It 
is  as  often  secondary  as  primary,  and  in  such  cases  it  is  a  con- 
comitant of  white  swelling,  a  disease  much  more  grievous  than 
the  dislocation,  and  almost  always  requiring  amputation. 

Luxation  forwards  is  still  more  rare  than  that  backwards; 
the  ligaments  of  the  knee  and  the  greater  part  of  the  tendons 
surrounding  it,  being  placed  nearer  its  posterior  than  anterior 
part,  prevent  the  too  great  extension  of  the  leg.  Luxations 
inwards  and  outwards  are  the  most  frequent.  They  are  always 
incomplete,  on  account  of  the  extent  of  the  articulating  sur- 
faces, and  the  strength  of  the  part  surrounding  the  articula- 
tion. They  take  place  from  the  femur  being  drawn  either  in- 
wards or  outwards,  while  the  leg  is  fixed. 

The  luxation  backwards  is  distinguished  by  attending  to  the 
following  circumstances:  it  is  impossible  to  extend  the  leg;  the 
patella,  closely  applied  to  the  pulley  of  the  femur,  forms  an 
eminence,  under  which  there  is  an  empty  space,  and  the  in- 
ferior ligament  is  extended  obliquely  downwards  and  back- 


BONES    OF    THE    LEG.  283 

wards;  and  a  proje£lion  formed  by  the  extremity  of  the  tibia, 
is  felt  in  the  ham,  &c.  &c. 

Symptoms  of  an  opposite  kind  accompany  the  luxation  for- 
wards. Those  inwards  and  outwards  are  easily  known  from 
the  deformity  of  the  joint.  In  the  first,  the  external  condyle 
of  the  femur  is  lodged  in  the  internal  cavity  of  the  tibia,  and 
the  internal  condyle  proje<^s  and  forms  a  tumour  at  the  in- 
ternal side  of  the  knee:  the  contrary  takes  place  in  the  se- 
cond. When  they  are  complete,  which  is  extremely  rare, 
the  tibia  is  carried  entirely  to  the  internal  or  external  side  of 
the  femur.  In  every  case  of  luxation  the  laceration  of  the 
ligamentous  parts  is  so  great,  that  the  ends  of  the  tibia  and 
femur  may  be  easily  placed  in  their  natural  situations;  there  is 
^^scarcely  occasion  for  even  gentle  extension  and  counter-exten- 
sion. It  happens  sometimes,  notwithstanding  the  extent  of  the 
articulating  surfaces,  that  a  return  of  the  luxation  takes  place 
from  the  great  laceration  of  the  parts  which  should  confine  the 
bones.  To  prevent  this,  an  apparatus  similar  to  that  used  in 
fradlures  of  the  thigh  is  to  be  applied.  Disagreeable  symptoms, 
occasioned  by  the  laceration  of  the  soft  parts,  are  always  to  be 
expedledj  our  attention  should  be  particularly  diredled  to  mo- 
derate and  subdue  them.  The  antiphlogistic  regimen  must  be 
stridlly  observed,  and  the  other  means  of  preventing  and  sub- 
duing inflammation  had  recourse  to.  If  the  inflammation  ter- 
minates in  suppuration,  the  abscesses  are  to  be  opened  by 
making  a  large  incision.  In  general,  large  openings  are  to  be 
made  in  abscesses  seated  in  the  neighbourhood  of  joints,  to  allow 
a  free  evacuation  of  the  pus,  which  by  stagnating  might  become 
acrid,  and  attack  the  cartilages  of  the  joint;  but,  if  the  abscesses 
be  formed  in  consequence  of  a  caries  of  the  ends  of  the  bones,  a 
very  small  opening  is  to  be  made,  in  order  to  prevent  as  much 
as  possible  the  admission  of  air.  If  the  inflammation  terminates 
in  gangrene,  we  must  wait  until  nature  has  arrested  the  progress 
of  the  mortification,  and  then  amputate.  The  separation  of 
the  living  from  the  dead  part,  is  marked  by  an  inflamed  circle. 
The  progress  of  the  mortification  is  very  often  so  rapid  that  it  is 
impossible  to  save  the  patient;  and  perhaps  a  complete  luxation 
of  the  tibia  from  the  femur  may  be  considered  as  a  case  re- 
quiring immediate  amputation.  However,  before  a  general 
precept  of  this  kind  can  be  established,  it  must  be  founded  on 
observations  well  made  and  judiciously  compared. 

The  fibula  is  difficultly  displaced  from  the  tibia,  with  which 
it  forms  two  articulation* ;  nevertheless  we  may  conceive,  that, 


lS4        OF  LUXATIONS  OF  THE  FOOT. 

in  a  violent  and  sudd&n  turn  outwrards  of  the  foot,  if  its  liga- 
ments are  naturally  relaxed,  it  may  slide  from  below  upwards, 
so  as  to  touch  the  external  condyle  of  the  femur.  Citizen 
Boyer  has  seen  a  luxation  of  this  kind  in  consequence  of  a  dis- 
location of  the  foot  outwards.  By  putting  the  foot  in  its  na- 
tural direftioh,  the  fibula  descended  into  its  proper  place. 
Compresses  soaked  in  resolvent  liquids  were  placed  over  the 
parts,  and  a  roller  was  passed  round  the  foot  and  leg,  to  pre- 
vent a  return  of  the  luxations.  The  patient  had  a  tardy  reco- 
very, and  some  stiffness  of  the  foot  remained,  though  the  pre- 
caution of  moving  it,  when  the  state  of  the  parts  would  admit 
it,  was  not  hegledled. 


CHAPTER  XVL 


OF  LUXATIONS  OF  THE  FOOT. 

THESE  luxations  are  but  seldom  met  with;  the  great  vio- 
lence necessary  to  produce  them,  and  the  difficulty  of 
effecting  them,  account  for  their  unfrequency.  Before  they 
can  take  place,  the  astragalus  must  be  partially  or  totally  forced 
from  the  quadrangular  cavity  formed  for  it  by  the  two  bones 
of  the  leg,  and  in  which  it  is  received  like  a  tenon  in  a  mor- 
tice. The  sides  of  the  articulation  are  strengthened  by  very 
strong  ligaments,  which  go  from  the  tibia  and  fibula  to  the  os 
calcis  and  astragalus,  and  by  the  two  malleoli.  An  external 
violence,  it  is  true,  may  distend  or  even  br^ieak  these  ligaments; 
but  its  force  being  almost  entirely  spent  in  producing  this  effe£t, 
will  not  be  sufficient  to  force  the  astragalus  from  the  cavity  in 
which  it  is  enclosed. 

The  foot  may  be  luxated  inwards  or  outwards,  forwards  or 
backwards,  and  the  luxation  in  any  of  these  direftions  may  be 
complete  or  incomplete.     Luxations  inwards  and  outwards  are 


OF  LUXATIONS  OF  THE  FOOT.         2S5 

the  most  frequent;  the  former  however  occurs  more  frequently 
than  the  latter:  the  internal  malleolus  not  descending  so  low  as 
the  external,  the  astragalus  has  a  less  space  to  describe  from 
without  inwards,  than  in  the  contrary  direction.  It  is  occa- 
sioned by  a  violent  abdu£tion  of  the  foot,  and  is  easily  known 
from  the  derangement  of  this  part,  the  sole  of  which  is  turned 
outwards,  and  the  back  inwards;  from  the  pain,  and  inability 
of  moving  the  foot;  and  lastly,  from  the  eminence  formed  be>- 
low  the  internal  malleolus  by  the  astragalus. 

In  the  luxation  outwards,  it  is  equally  impossible  to  move 
the  foot;  the  sole  is  turned  inwards  and  the  back  outwards, 
and  the  astragalus  forms  an  eminence  below  the  external  mal- 
leolus. 

Luxations  of  the  foot  are  always  dangerous;  their  conse- 
quences may  be  so  dreadful  as  to  occasion  death,  and  in  very 
many  cases  they  render  amputation  necessary.  However,  the 
prognosis  is  not  always  so  unfavourable;  for  it  is  clearly  pro- 
ved, that  many  patients  have  recovered  without  any  thing  ex- 
traordinary having  occurred  during  their  treatment.  This  in- 
validates the  general  rule  laid  down  by  J.  L.  Petit,  to  ampu- 
tate before  twenty-four  hours  after  the  luxation.  It  is  also  now 
well  ascertained  that  dislocations  likely  to  produce  the  most 
mischievous  consequences,  have  had  a  happy  termination,  and 
that  this  was  the  case,  though  the  soft  parts  have  been  very 
much  injured,  the  ligaments  nearly  quite  ruptured,  and  the 
astragalus  completely  removed  from  the  foot. 

The  reduction  should  be  accomplished  as  soo»  as  possible,  in 
every  luxation  of  the  foot;  if  deferred,  the  inflammatory  symp- 
toms and  swelling  which  supervene,  will  render  it  diiHcult  and 
painful.  To  effect  this,  one  assistant  makes  counter-extension 
by  fixing  the  leg,  and  another  draws  the  foot,  whilst  the  sur- 
geon pushes  the  latter  part  in  a  direftion  contrary  to  that  in 
which  it  was  luxated.  If  the  luxation  be  inwards,  the  external 
edge  of  the  foot  must  be  depressed  by  elevating  the  internal, 
when  it  is  found  that  the  ligaments  yield  to  the  extension:  the 
contrary  is  done  in  luxations  outwards.  The  articulation  is 
covered  with  compresses  moistened  with  resolvent  liquids;  and 
splints  which  reach  below  the  sole  of  the  foot,  are  applied  on 
the  inside  and  outside  of  the  leg. 

Consequences  more  or  less  disagreeable  are  always  to  be  es- 
pefted,  which  may  be  moderated  or  even  prevented  by  copious 
and  repeated  bleedings.  Sometimes,  notwithstanding  the  enor- 
mous derangement  and  laceration  of  the  soft  parts,  no  bad 


286         OF  LUXATIONS  OF  THE  FOOT. 

symptom  succeeds,  and  the  patient  recovers  with  an  unexpect- 
ed rapidity;  but  in  very  many  cases,  violent  inflammation  su- 
pervenes and  quickly  terminates  in  gangrene.  In  other  cases 
the  inflammation  terminates  in  suppuration,  abscesses  form  and 
heal  up,  and  the  patient  recovers.  Sometimes,  however,  there 
is  a  caries  of  the  ends  of  the  bones  conjoined  with  them. 

The  experienced  praftitioner  is  to  judge,  from  the  nature 
and  violence  of  the  symptoms,  when  immediate  amputation  is 
necessary.  A  great  number  of  observations  posterior  to  those 
of  J.  L.  Petit,  prove  that,  by  following  his  instru(Slions,  we 
should  often  amputate  a  limb  which  might  be  preserved.  It  is 
also  ascertained  by  experience,  that  the  astragalus  may  be  ex- 
tirpated with  advantage,  when  the  laceration  is  such,  that  it  is 
only  attached  by  a  few  shreds  of  ligament.  The  tibia,  in  con- 
sequence of  this  extirpation,  descends,  and  rests  on  the  supe- 
rior face  of  the  os  calcis,  to  which  it  grows,  and  the  patient 
recovers,  it  is  true,  with  an  anchylosed  joint;  but  such  a  termi- 
nation is  preferable  to  losing  the  foot  by  amputation,  or  run- 
ning the  risk  of  the  dangerous  symptoms  arising  from  preser- 
ving the  astragalus.  Ferrand  performed  this  operation  on  an 
invalided  soldier,  who  was  in  the  habit  of  carrying  the  bone  in 
his  pocket.  Desault  performed  it  three  times  with  success. 
One  of  his  three  patients  (a  female)  died  three  months  after 
the  operation;  but  she  evidently  fell  a  vitSlim  to  an  hospital 
fever,  which  was  by  no  means  connedted  with  the  complaint 
for  which  she  was  admitted  into  the  hospital.  On  dissecting 
the  foot,  the  extremity  of  the  tibia  was  found  already  partially 
attached  to  the  os  calcis.  There  is  no  doubt  but  that  the  ope- 
ration would  have  been  crowned  with  success,  had  the  person 
survived  the  other  disease. 

Fracture  of  the  fibula  near  its  inferior  extremity,  is  a  fre- 
quent complication  of  luxation  of  the  foot  inwards.  This  bone 
is  to  be  carefully  examined  in  all  such  cases,  and  the  foot  is  to 
be  supported,  whether  the  fibula  be  fractured  or  not,  by  means 
of  the  ordinary  apparatus  for  fra<ftures  of  the  leg. 

Luxations  forwards  and  backwards,  less  frequent  than  tho^e 
described,  are  however  sometimes  met  with.  The  first  is  occa- 
sioned by  a  fall  backwards,  while  the  foot  is  fixed  to  the 
ground;  the  second  by  a  fall  on  the  feet,  with  the  body  inclined 
forwards,  and  the  leg  much  bent.  The  luxation  forwards  is 
more  difficultly  produced  than  that  backwards,  on  account  of 
the  articular  pulley  of  the  astragalus,  which  inclines  towards 
the  posterior  side,  being  permitted  to  slide  much  on  the  tibia. 


OF    LUXATIONS    OF    THE    FOOT.  IS7 

^frlthout  abandoning  it  in  the  extension  of  the  foot.     When 
the  extension  is  carried  too  far,  luxation  forwards  is  produced. 

In  the  luxation  backwards,  the  external  and  posterior  liga- 
ments, and  the  posterior  part  of  the  capsule,  are  torn;  in  that 
forwards,  the  anterior  and  external  ligaments,  the  anterior 
fibres  of  the  internal  lateral  ligament,  and  the  anterior  part  of 
the  capsule,  are  torn.  The  symptoms  of  the  first  species  are, 
a  diminution  of  length  in  that  part  of  the  foot  between  the  lower 
part  of  the  leg  and  the  anterior  extremity  of  the  toes,  elonga- 
tion of  the  heel,  tension  of  the  ten  do  Achillis,  and  relaxation 
of  the  extensors  of  the  toes.  It  is  impossible  either  to  bend  or 
extend  the  foot:  this  symptom  distinguishes  luxation  from 
sprain,  in  which  the  foot  may  be  moved,  though  not  without 
pain,  however  high  the  inflammatio,n  may  be. 

Contrary  symptoms  accompany  the  luxation  forwards :  the 
foot  is  lengthened,  the  heel  is  shortened,  and  the  foot,  much 
extended,  cannot  be  bent,  &c. 

The  redu^ion  of  both  is  easily  effedted ;  after  which  it  will 
be  necessary  to  use  efFeflual  means  to  prevent  a  relapse.  The 
mode  of  treatment  to  be  afterwards  observed,  for  subduing  the 
unfavourable  symptoms  that  supervene,  is  the  same  as  that 
pointed  out  for  luxations  inwards  and  outwards.  "When  gan- 
grene takes  place  in  any  luxation  of  the  foot,  we  must  defer 
amputation  until  its  ravages  are  arrested.  In  cases  where  the 
inflammation  is  moderate,  and  the  destruftion  of  the  soft  parts 
not  considerable,  the  articulation  may  be  preserved;  and  to 
prevent  a  stiffness  of  the  joint,  the  foot  is  to  be  moved  as  soon 
as  circumstances  will  admit  of  it. 

The  very  thick  and  short  ligamentous  substance  which  unites 
the  astragalus  to  the  os  calcis,  binds  them  so  strongly  together, 
that  they  follow  one  another  in  their  motions,  and  form,  as  it 
were,  but  one  bone.  Hence  they  are  never  completely  sepa- 
rated, even  in  the  most  desperate  cases  of  luxation  of  the  foot; 
but  one  or  both  of  them  may  be  luxated  from  the  scaphoides 
and  cuboides.  The  transverse  dire(Stion  of  the  articulation 
formed  by  these  four  bones,  suggested  to  Chopart  the  inge- 
nious idea  of  amputating  only  a  part  of  the  foot.  But  these 
luxations,  less  dangerous  thau  the  others,  can  be  occasioned 
only  by  a  violent  effort,  in  which  the  anterior  part  of  the  foot 
is  fixed,  as  happened  in  the  two  cases  related  by  J.  L.  Petit: 
the  foot  was  fastened  in  an  iron  grate,  whilst  the  body  was 
drawn  backwards.  The  astragalus  and  os  calcis  may,  under 
these  circumstances,  be  luxated,  but  particularly  the  former, 


i88        OF  DROPsy  OF  the  articulations. 

the  head  of  which  slides  from  below  upwards,  in  the  cavity  of 
the  posterior  face  of  the  scaphoides,  and  forms  a  tumour  on 
the  back  of  the  foot.  The  inflammatory  swelling  renders  it 
often  difficult  to  ascertain  this  luxation.  It  is  not  easily  re- 
duced, even  shortly  after  it  has  taken  place.  Citizen  Boyer 
failed  in  a  case  of  this  kind,  in  which  the  head  of  the  astraga- 
lus was  luxated  upwards  and  inwards,  by  a  fall  from  a  horse; 
but  in  some  time  the  person  felt  no  inconvenience  from  the 
affe£tion,  he  could  walk  without  pain  or  lameness,  and  nothing 
remained  but  the  deformity  occasioned  by  the  tumour. 

The  other  bones  of  the  tarsus  and  metatarsus  are  too  strongly 
tied  together  to  admit  of  luxation.  The  phalanges  of  the  toes 
cannot  be  luxated  by  external  violence,  on  account  of  their 
shortness.  However,  the  possibility  of  luxation  of  the  first 
phalanx  of  the  great  toe  from  the  first  bone  of  the  metatarsus 
may  be  easily  conceived.  It  is  not  necessary  to  give  here  the 
rules  to  be  followed  in  such  a  case.  They  consist  in  reducing 
the  luxation,  and  amputating  the  great  toe,  when  the  state  of 
the  soft  parts  renders  it  impossible  to  preserve  it. 


CHAPTER  XVII. 


OF  DROPSY  OF  THE  ARTICULATIONS. 

THE  synovial  fluid,  which  lubricates  the  surfaces  of  all 
the  joints,  may  be  accumulated  in  such  quantity  in  the 
capsule  which  secretes  it,  as  to  form  a  disease  called  by  authors 
hydarthrus,  or  dropsy  of  the  joint.  Though  the  possibility  of 
this  accumulation  taking  place  in  all  the  articulations  may  be 
conceived,  yet  there  is  no  well-attested  instance  of  this  happen- 
ing in  any  of  them  but  in  the  knee. 

Dropsy  of  the  joints  seldom  depends  on  a  general  affe<Slion 
of  the  system,  and  rarely  co-exists  with  other  dropsical  af- 


OF    DROPSY    OF    THE    ARTICULATIONS.  289 

feftions,  such  as  hydrothorax,  ascites,  and  anasarca.  It  ap- 
pears to  be  a  partial  afFeftion,  and  to  be  produced  by  local 
causes,  which  a6l  by  destroying  the  balance  between  the  ex- 
halation and  absorption  of  the  synovia.  The  accumulation  of 
this  sero-albuminous  fluid  seems  to  arise  in  most  cases  from  an 
increased  exhalation,  and  not  from  a  diminution  of  absorption. 
In  fact,  affedlions  of  this  kind  come  on,  in  general,  from  vio- 
lent exercise  of  the  articulation,  from  fatiguing  the  hgamcnts, 
and  from  the  repeated  friction  of  its  surfaces  in  too  long  and 
laborious  exercise. 

Motion,  as  we  have  established  in  another  work,  is  the  prin- 
cipal stimulus  by  which  the  secretion  of  the  synovia  is  increased, 
and  the  fluids  determined  to  the  joint.  This  determination  is 
considerable  in  proportion  to  the  friction  and  pressure  of  the 
ends  of  the  joint  against  one  another.  When  this  stimulus  is 
carried  to  a  certain  degree,  an  acStive  exhalation,  or  rather 
slight  phlogosis,  is  produced,  and  the  serous  secretion  is  very 
considerably  increased.  It  is  in  a  similar  way  that  dropsies  of 
the  breast  and  abdomen  are  often  occasioned  by  a  slow  and  la- 
tent inflammation  of  the  pleura  or  peritoneum. 

The  nqf^ure  of  the  remote  causes  of  hydarthrus  corroborates 
what  we  have  advanced  concerning  its  formation.  It  is  very 
often  a  consequence  of  acute  rheumatism,  and  sometimes  forms 
a  crisis  of  that  disease.  Many  observers,  and  particularly 
Storck,  have  remarked  the  tendency  which  acute  rheumatism 
has  to  terminate  by  an  effusion  of  a  sero-lymphatic  fluid  into 
the  cellular  substance  in  the  neighbourhood  of  the  joints  of  the 
lower  extremities,  or  into  the  interior  of  the  joint  itself.  The 
more  rapid  the  progress  of  the  inflammatory  symptoms,  the 
more  prompt  is  the  effusion,  consequently  it  takes  place  slowlj'- 
in  chronic  rheumatism  and  in  chronic  gout.  The  swelling  of 
the  joints  in  these  complaints,  and  the  deposition  of  matter 
which  takes  place  into  the  parts  about  the  articulation,  may 
also  produce  an  increased  exhalation  of  synovia.  The  pains 
which  accompany  white  swellings  often  occasion  an  accumula- 
tion of  synovia  in  the  capsule  of  the  joint.  I  have  seen,  in 
dissedting  two  of  these  swellings  of  the  knee,  the  synovia  col- 
lected nearly  to  the  quantity  of  two  ounces. 

But  we  must  remember  that  the  inflammation  which  pro- 
duces dropsy  of  the  joint  is  only  slight-,  if  very  considerable,  it 
would  suspend  the  secretion  of  synovia,  and  give  rise  to  anchy- 
losis by  the  mutual  adhesion  of  the  dried  surfaces  of  the  joint. 
AVe  are  decidedly  of  opinion,  that  the  articulation  of  the  knee 
'J7 


igO  OP    DROPSY    OF    THE    ARTICULATIONS. 

only  has  hitherto  presented  a  colleftion  of  synovia  sufficient  to 
merit  the  name  of  dropsy:  such  an  accumulation  never  takes 
place  in  the  hip  joint,  though  J.  L.  Petit  attempts  to  explain 
spontaneous  luxations  of  the  femur  from  this  cause. 

We  must  not  confound  this  disease  with  encysted  tumours, 
which  are  sometimes  formed  on  the  sides  of  the  knee  near  the 
patella.  The  latter  are  circumscribed,  and  a  fluctuation  is  felt 
in  them;  they  are  not  accompanied  with  pain  or  discolouration 
of  the  skin;  on  opening  them,  an  albuminous  fluid  escapes, 
and  the  sides  of  the  cyst  are  niade  to  adhere  to  one  another  by 
pressure ;  or  when  this  does  not  succeed,  by  means  of  an  irri- 
tating injedlion,  which  excites  an  inflammation  on  its  surface. 
This  practice  is  free  from  danger,  because  the  cyst  is  shut  on 
all  sides,  and  has  no  communication  with  the  interior  of  the 
joint.  We  must  also  take  care  not  to  confound  with  dropsy 
of  the  joint  certain  white  swellings,  in  which  the  cellular  sub- 
stance, distended  with  fluid,  presents  a  kind  of  fluctuation. 
This  symptom  is  particularly  apt  to  lead  into  error  in  swellings 
of  the  cluster  of  lymphatic  and  sebaceous  glands  situated  above 
the  patella,  between  the  tendon  of  the  extensor  muscles  of  the 
leg  and  the  anterior  and  inferior  part  of  the  femiif.  In  the 
commencement  of  some  white  swellings,  this  tissue,  distended 
with  lymph,  elevates  and  pushes  forwards  the  tendon  of  the 
extensors  of  the  leg,  displaces  the  patella,  and  raises  it  up 
from  the  condyles  of  the  femur.  In  these  cases,  the  patella  is 
replaced  by  pressure,  and  the  swelled  mass  being  displaced, 
forms  two  tumours  at  the  sides  of  the  tendon,  which  are  tense 
and  elastic,  and  have  an  internal  motion;  but  the  sensation 
communicated  by  this  motion  is  very  diflerent  from  that  occa- 
sioned by  the  undulation  of  a  fluid:  it  is  like  that  of  something 
Slipping  from  under  the  finger.  However,  there  is  such  simi- 
larity in  these  symptoms,  that  an  inattentive  surgeon  may  be 
easily  led  into  error. 

Arthritic,  cedematous,  and  white  swellings  of  the  knee,  and 
foreign  bodies  formed  in  it,  are  accompanied  with  symptoms 
so  different  from  those  of  dropsy  of  this  joint,  that  there  is  no 
occasion  to  point  them  out  here.  The  marks  by  which  the 
existence  of  the  latter  affection  is  ascertained  are  these:  a  dull 
pain  is  felt  in  the  articulation,  the  knee  loses  its  oval  form,  and 
presents  an  irregular  colourless  tumour,  in  which  a  fluctuation 
is  felt  at  those  places  where  the  capsule  is  slack,  and  forms  little 
round  eminences  which  project  about  the  joint.  The  most  con- 
siderable of  these  arc  placed  at  the  sides  of  the  patella,  which 


#        OF    DROPSy    OF    THE    ARTICULATIONS.  2gi 

is  itself  pushed  upwards  by  the  fluid,  but  it  may  be  replaced  by 
bending  the  leg.  The  form  of  the  tumour  is  varied  by  the  mo- 
tions of  the  knee;  but  it  always  proje<^ts  more  at  the  anterior 
part  of  the  articulation  than  in  the  ham,  at  which  place  the 
synovial  membrane  presents  only  a  small  surface,  and  is  sup- 
ported by  the  cross  ligaments  which  pass  behind  it.  A  flu<Slur 
ation  is  felt  by  striking  the  tumour;  the  thinness  of  the  soft 
parts  renders  it  very  easy  to  ascertain  the  undulation  of  the 
fluid.  The  nature  of  the  disease  is  sufficiently  manifest  when 
all  these  symptoms  are  present. 

The  prognosis  is  unfavourable,  on  account  of  the  difficulty 
of  discussing  the  tumour,  and  the  danger  of  a  caries  of  the  car- 
tilages and  ends  of  the  bones,  or  an  anchylosis,  supervening. 

As  dropsy  of  the  knee-joint  never  depends  on  the  causes 
which  produce  general  dropsy;  and  as,  instead  of  appearing  in 
persons  labouring  under  general  debility,  it  is  always  met  with 
in  the  strong  and  robust,  a  particular  mode  of  treatment  is  re- 
quired in  it.  Stimulants,  purgatives,  diuretics,  or  sudorifics, 
are  either  useless,  or  at  least  can  give  but  a  very  feeble  assist- 
ance. It  is  from  topical  applications  that  benefit  is  to  be  ej^- 
peifted.  The  mildest  of  these  are  to  be  commenced  with,  and 
they  in  general  succeed  in  recent  cases,  in  which  the  efllision 
has  not  been  considerable,  and  has  been  suddenly  formed  in  a 
crisis  of  acute  rheumatism,  or  any  other  acute  disease.  Resol- 
vent liquids,  such  as  camphorated  spirit  of  wine,  frictions  with 
a  brush,  or  warm  flannel  impregnated  with  some  aromatic  va- 
pour, with  volatile  camphorated  liniment,  alcohol,  ether,  or 
even  with  mercurial  ointment  as  advised  by  Bell,  determine  the 
fluids  to  the  skin,  increase  the  insensible  perspiration  of  which  it 
is  the  organ,  and  promote  the  absorption  of  the  effused  fluid. 
Fumigations  with  the  vapour  of  vinegar,  from  which  Monro 
witnessed  good  effects,  with  the  vapour  of  benzoin  and  other 
balsams,  and  pumping  with  warm  water  in  which  neutral  salts 
have  been  dissolved,  a£t  in  the  same  manner.  But  of  all  topical 
stimulants,  the  most  ac^live  and  most  effecHiual  is  a  blistering 
plaster,  in  which  the  proportion  of  cantharides  is  not  so  consi- 
derable as  to  cause  great  vesications.  Tralles  used  synapisms, 
and  Storek  applied  cataplasms  of  the  ranunculus.  We  must, 
however,  take  care  not  to  carry  the  use  of  these  remedies  so 
far  as  to  disorganize  the  structure  of  the  cellular  tissue,  which 
often  occasions  ulcers  difficult  to  cure,  and  extremely  painful. 
For  the  same  reasons  we  are  not  to  use  cupping  and  scarifying 
but  with  great  circumspe£lion. 


292  OF    DROPSY    OF    THE    ARTICULATIONS.         W 

When  all  these  means  have  been  used  for  a  sufficient  time 
■without  any  benefit,  and  when  the  turnour  impedes  the  mo- 
tion, and  causes  a  contraction  and  atrophia  of  the  limb,  we 
must  have  recourse  to  a  surgical  operation.  It  consists  in  ma- 
king a  puncture  with  a  trocar  into  the  cavity  of  the  tumour, 
and  allowing  the  water  to  escape  through  the  canula.  This 
operation,  though  easily  performed,  is  a  delicate  and  danger- 
ous one,  on  account  of  the  admission  of  air  into  the  joint. 
The  conta£t  of  air  has  not,  as  we  shall  see  in  treating  of  wounds 
of  the  articulations,  all  the  bad  effefts  attributed  to  it  by  au- 
thors. However,  the  morbid  state  of  the  synovial  membrane, 
and  the  irritation  already  existing  in  it,  may  render  it  more 
sensible  to  the  impression  of  this  fluid  than  it  would  be  were 
there  no  disease  in  the  joint;  and,  in  faft,  cases  have  occurred 
in  which  the  qualities  of  the  synovia  were  considerably  changed 
by  the  contact  of  air:  this  fluid,  instead  of  being  inodorous,  ac- 
quired a  disagreeable  odour,  lost  its  transparency  by  the  mix- 
ture of  a  purulent  matter,  produced  an  inflammation  which 
extended  to  the  capsule  and  cartilages,  and  at  last  occasioned  a 
caries  of  the  ends  of  the  bones. 

To  prevent  these  direful  consequences,  and  the  introduftion 
of  air  which  occasions  them,  a  superficial  incision  is  to  be  made 
in  the  skin  at  the  most  projecting  part  of  the  tumour;  after 
which,  the  lips  of  the  wound  are  to  be  much  separated,  and 
the  trocar  used  in  the  operation  for  the  hydrocele,  pushed  cau- 
tiously in  an  oblique  direction  from  the  bottom  of  the  incision 
into  the  cavity  of  the  tumour.  The  skin  collapses  after  the 
evacuation  of  the  water,  and  covers  the  pundture  made  by  the 
trocar,  the  canula  of  which  is  to  be  drawn  away  when  all  the 
water  has  drained  ofi\ 

"When  the  operation  is  finished,  the  patient  is  to  be  put  to 
bed  with  his  knee  half  bent ;  the  joint  is  to  be  covered  with 
cloths  wet  with  spirituous  liquors,  or  other  astringent  fluids, 
with  the  view  of  preventing  the  return  of  the  efixision.  We 
will  m.ention,  in  the  chapters  on  white  swellings  and  anchylo- 
sis, the  treatment  to  be  adopted  in  cases  in  which  the  synovia 
has  its  qualities  changed,  and  produces  caries  or  anchylosis. 


293 


CHAPTER  XVIII. 


OF  FOREIGN   BODIES  FORMED  IN.  THE 
ARTICULATIONS. 

THE  foreign  bodies  which  are  formed  and  developed  in  the 
interior  of  the  articulations,  are  to  be  carefully  distin- 
guished from  arthritic  concretions  deposited  in  their  neighbour- 
hood. These  foreign  bodies,  which  alone  will  be  considered 
in  this  chapter,  may  take  their  origin  in  the  inside  of  every  ar- 
ticulation in  which  there  is  motion.  They  have  been  found  in 
the  articulation  of  the  lower  jaw  with  the  temporal  bones,  in 
that  of  the  wrist  with  the  bones  of  the  fore-arm,  and  that  of 
the  foot  with  the  leg  ;  but  no  joint  is  more  subjecl  to  them  than 
the  knee.  Ambrose  Pare  has  made  mention  of  these  substan- 
ces ;  latterly,  praftitioners  have  directed  their  attention  to  them, 
and  have  proposed  methods  of  removing  them. 

These  foreign  bodies  have  various  appearances,  and  are  found 
in  greater  or  less  quantity :  sometimes  they  resemble  a  frag- 
ment of  cartilage,  which  moves  about  in  the  joint,  but  which 
is  attached  to  the  capsular  membrane-,  at  other  times  they  are 
detached,  hard,  and,  as  it  were,  inorganic,  and  can  be  moved 
to  any  part  of  the  joint.  A  concretion  of  this  kind,  the  size 
of  a  large  hazel-nut,  was  found  in  the  knee  of  a  woman  who 
died  in  the  hospital  Saint  Louis.  Citizen  Fourcroy,  who  has  it 
in  his  possession,  compares  it  to  tubercles  found  in  certain  fishes, 
for  instance,  to  those  on  which  the  prickles  of  the  ray-fish  are 
elevated.  As  to  their  number,  it  varies,  from  one,  which  is 
the  most  common,  to  twenty-five,  a  number  at  first  sight  very 
considerable,  but  for  which  we  have  the  incontestable  evidence 
of  the  illustrious  Morgagni.  Their  size  is  very  variable  ;  some 
have  been  found  of  an  inch  and  a  half  in  their  greatest  diameter, 
whilst  others  have  scarcely  equalled  the  size  of  a  lentil.  They 
have  generally  the  form  of  this  seed,  but  they  have  been  met 
with  of  various  forms,  as  long,  oval,  rough,  or  broken  on 
their  surface,  concave,  or  convex.  The  chemical  analysis  of 
them  shews  that  the  cartilaginous  ones  are  chiefly  composed  of 


294  OF    FOREIGN    BODIES 

albumen,  and  the  hard  solid  ones  principally  of  phosphate  of 
lime. 

It  is  difacuU,  without  doubt,  to  give  an  explanation  of  the  ori- 
gin and  growth  of  these  substances,  but  it  is  certain  that  they  al- 
ways impede  more  or  less  the  motion  of  the  joint  in  which  they 
grow.  Sometimes  they  succeed  to  the  swelling  and  contusion 
occasioned  by  a  fall  or  blow  on  the  knee  ;  at  other  times  they 
arc  formed  spontaneously  without  any  apparent  cause  ;  and  in 
both  cases  their  presence  is  indicated  by  tumefaction  of  the 
knee,  which  is  increased  by  rest,  and  diminished  by  moderate 
exercise.  Are  they  formed  by  the  crystallization  of  the  salts 
held  in  solution  by  the  synovia,  in  the  same  way  as  the  crystal- 
lizable  parts  of  the  urine  form  calculi  in  the  bladder  ?  How,  in 
this  case,  do  they  become  organized  ?  for  many  of  them  have 
vessels,  and  evident  marks  of  organization.  Theden  supposed 
that  they  were  formed  by  a  portion  of  the  synovial  cluster 
of  glands  on  the  outside  of  the  capsule,  which  was  bruised 
and  nearly  detached  by  the  shock  occasioned  by  a  false  step. 
Some  authors  have  imagined  that  they  were  portions  of  car- 
tilage detached  from  those  covering  the  ends  of  the  bones, 
or  placed  between  them.  Morgagni  ascertained  that  they 
could  not  originate  in  this  manner,  for  the  articulation  and  car- 
tilages were  perfetStly  sound  and  whole  in  the  subjefts  in  whom 
they  were  found  in  the  greatest  number.  Nothing  then  is 
more  obscure  than  the  etiology  of  this  affection.  Happily, 
though  its  causes  are  involved  in  obscurity,  it  is  easily  distin- 
guished, and  can  be  treated  with  great  hopes  of  success. 

If  these  substances  are  free  and  detached,  they  can  pass  ea- 
sily from  one  part  to  another  of  the  articulation,  and  enter  in- 
to all  its  corners  •,  in  this  case,  it  is  difficult  to  establish  the  ex- 
istence of  them,  but  it  is  particularly  difficult  to  extract  them  ; 
the  moveable  body,  whilst  we  are  making  the  incision  to  ex- 
tract it,  may  slide  from  the  place  where  it  projedled  under  the 
skin,  and  fall  into  the  cavity  in  the  posterior  part  of  the  knee. 
Sometimes  it  occasions  no  pain :  this  arises  from  the  body  be- 
ing fixed  in  some  place  in  which  it  does  not  impede  the  motion 
of  the  knee ;  as,  for  example,  at  the  sides  of  the  patella,  or 
of  the  tendon  of  the  extensors  of  the  leg.  At  other  times  it 
occasions  much  distress:  this  is  caused  by  its  being  placed  be- 
tween the  posterior  face  of  the  patella  and  the  articular  pulley 
of  the  femur.  As  it  can  occupy  alternately  these  different 
places,  it  is  easy  to  explain,  as  Bell  observes,  why  patients  af- 
fected with  this  complaint  are  often  roused  from  their  sleep  by 


Formed  in  the  articulations.  295 

sharp  pains  arising  from  the  change  of  situaticn  of  the  body 
during  sleep. 

A  more  or  less  considerable  enlargement  takes  place  round 
the  knee  during  the  continuance  of  the  pains,  but  it  is  still  easy 
to  feel  the  body  through  the  skin  and  capsule.  It  forms  an  emi- 
nence under  the  integuments,  and  may  be  pushed  in  any  di- 
retftion,  and  made  to  projevSt  at  the  internal  or  external  sides  of 
the  inferior  ligament  of  the  patella,  at  the  internal  cr  external 
sides  of  this  bone  itself,  or  of  the  tendon  of  the  extensors  of 
the  leg.  Sometimes  the  laxity  of  the  integuments  and  capsule 
is  so  great,  that  we  can  seize  the  body  and  twist  it.  Desault 
has  seen  a  case  of  this  kind. 

It  is  impossible  to  obtain  a  resolution  of  these  substahces. 
This  desirable  termination  cannot  take  place  but  by  means  of 
vital  adtion  ;  now,  this  aftion  is  so  little  to  be  expeOed  in  the 
greatest  number  of  them,  they  being  in  some  degree  inorganic, 
and  topical  stimulants  and  resolvents  can  aft  with  so  little  efFedt 
through  the  integuments,  that  the  removal  of  them  by  these 
means  is  scarcely  to  be  looked  for.  Some  English  surgeons 
have  proposed  to  fix  and  confine  the  body  in  a  part  of  the  ar- 
ticulation where  it  could  not  impede  motion,  and  where  it 
might  form  an  adhesion  with  the  capsule ;  but  how  are  we  to 
confine  a  body  which  tends  incessantly  to  change  its  situation  ? 
Besides,  the  adhesion  cannot  be  formed  without  a  certain  de- 
gree of  inflammation  in  both  surfaces,  of  which  the  foreign 
substance  is  very  rarely  susceptible.  Lastly,  should  the  adhe- 
sion, which  requires  a  certain  degree  of  organization  in  the  body, 
take  place,  the  concretion  would  be  susceptible  of  growth, 
and  in  time  would  impede,  by  its  size,  the  motion  of  the  knee. 

The  most  simple,  prompt,  and  certain  method  of  cure,  is 
the  extraction  of  the  foreign  body,  an  operation  always  easily 
performed,  and  free  from  danger,  if  the  following  rules  are 
observed.  The  patient  being  stretched  on  his  back,  with  the 
leg  extended,  in  order  to  relax  the  soft  parts  at  the  anterior  of 
the  articulation,  the  surgeon  looks  for  the  foreign  body,  and 
bringing  it  to  the  internal  side  of  the  patella,  at  which  place 
the  capsule  is  very  lax,  fixes  it  with  his  thumb  and  fore-finger. 
An  assistant  draws  outwards  the  skin  over  the  patella,  and  the 
surgeon  makes  a  longitudinal  incision,  through  the  integuments, 
on  the  body.  The  incision  should  be  made  deep  enough  by 
one  stroke  of  the  knife,  and  proportioned  to  the  size  of  the 
body  to  be  extrafted.  Sometimes  it  is  forced  through  the  in- 
cision by  compressing  it  between  the  fingers.     If  it  be  attached 


1^6  OF    FOREIGN    BODIES 

by  a  fold  of  the  capsule,  which  serves  it  as  a  ligament,  this 
is  to  be  divided  with' a  history  or  scissarsj  if  there  be  occa- 
sion to  enlarge  the  incision,  it  is  to  be  done  with  the  knife ; 
and  pincers,  or  other  instrun:ients  which  may  lacerate,  bruise, 
or  occasion  inflammation  of  the  surfaces  of  the  joint,  are  never 
to  be  intrqduced.  The  substance  being  extracted,  the  assistant 
removes  his  hand,  and  leaves  the  skin  to  its  own  elasticity, 
which  brings  over  the  wound  in  the  capsule  the  portion  of  the 
integuments  which  had  been  drawn  to  one  side. 

By  making  the  incision  in  this  way,  the  admission  of  air  into 
the  joint  is  prevented,  and  all  the  bad  consequences,  such  as 
inflammation,  suppuration,  and  caries,  are  obviated. 

After  having  extracted  one,  or  as  many  bodies  as  may  be 
found  in  the  articulation,  the  lips  of  the  wound  are  imme- 
diately brought  together  by  means  of  adhesive  plaster ;  some 
compresses,  wet  with  resolvent  liquids,  are  applied  over  the 
joint,  and  the  whole  dressing  is  supported  by  some  turns  of  a 
roller  drawn  pretty  tight.  The  leg  is  to  be  placed  on  a  pillow, 
and  kept  extended,  in  order  to  relax  the  soft  parts  about  the 
incision,  and  thus  prevent  pain  and  the  approach  of  inflamma- 
tion. 

Though  the  precaution  of  making  the  incision  in  the  skin, 
in  a  line  difierent  from  that  in  which  it  is  made  in  the  capsule, 
is  rational,  yet  it  is  not  absolutely  necessary  to  the  success  of 
the  operation.  Many  surgeons  have  omitted  it,  and  afterwards 
obtained  the  immediate  union  of  the  divided  parts;  which 
proves,  as  will  be  mentioned  in  treating  of  wounds  of  the 
joints,  that  wounds  of  the  articulations  are  attended  with  less 
danger  than  the  ancients  and  a  great  number  of  the  moderns 
have  imagined.  The  pain  occasioned  by  the  extradlion  is  in- 
considerable, but  it  may  be  acute,  if  the  patient  be  extremely 
sensible  to  impressions,  or  if  a  considerable  branch  of  the  in- 
ternal saphena  nerve,  which  is  very  variable  in  its  diredlion, 
come  under  the  edge  of  the  history.  The  loss  of  blood,  when 
even  one  of  the  articular  arteries  is  divided,  is  very  inconside- 
rable; it  scarcely  merits  the  name  of  hsemorrhage,  and  is  easily 
stopped  by  bringing  together  the  sides  of  the  wound.  For 
some  days  after  the  operation,  the  compresses  should  be  fre- 
cjuently  moistened  with  resolvent  liquids,  and  the  knee  kept 
perfedlly  at  rest;  the  patient  should  not  be  permitted  to  rise 
before  the  fifteenth  or  twentieth  day,  though  the  wound  may 
have  cicatrized  in  the  first  week;  for  it  is  much  better,  in  these 
cases  to  carry  precaution  too  far,  than  to  be  deficient  in  it. 


FORMED    IN    THE    ARTICULATIONS.  297 

When,  on  account  of  the  admission  of  air  into  the  articula- 
tion, or  the  improper  use  of  instruments  in  extracting  the  body, 
inflammation  takes  place,  it  is  combated  by  emollient  applica- 
tions and  copious  and  repeated  bleedings.  If  abscesses  form, 
they  are  to  be  opened;  and  when  the  symptoms  have  abated, 
the  limb  is  to  be  gently  moved,  and  the  motion  increased  every 
day,  in  order  to  prevent  a  stiffness  of  the  joint.  All  the  ob- 
servations that  we  have  made  here  respedling  these  bodies  are 
applicable  to  those  only  found  in  the  knee;  and  this  is  the  only 
joint  on  which  it  has  been  necessary  to  perform  an  operation  in 
order  to  remove  them.  Their  presence  in  other  articulations 
would  not  be  so  easily  discovered,  neither  would  it  cause  the 
same  inconveniences.  Should  extraftion,  in  these  cases,  be 
necessary,  the  operation  would  be  so  much  the  more  danger- 
ous, as  the  joint  is  deep-seated,  and  surrounded  with  import- 
ant parts. 


CHAPTER  XIX. 


OF  WOUNDS  OF  THE  ARTICULATIONS. 

ALIj  the  ancient  writers  on  surgery  speak  in  the  same 
terms  of  the  danger  of  wounds  of  the  articulations;  and 
almost  all  modern  authors  are  of  their  opinion.  We  will  prove, 
in  this  chapter,  that  wounds  of  the  articulations,  sometimes 
followed  by  serious  consequences,  often  heal  with  the  greatest 
facility,  and  that  the  apprehensions  of  authors  respefting  them 
are  imfounded. 

A  man  was  wounded  in  the  elbow  by  a  piece  of  glass,  which 
penetrated  into  the  cavity  of  the  joint.  The  glass  was  extra«rt- 
ed,  and  the  lips  of  the  wound  were  brought  together,  and 
supported  by  adhesive  plaster;  his  recovery  was  quick,  and 
not  interrupted  by  any  unfavourable  circumstance. 
38 


293  OF    WOUNDS    OF    THE    ARTICULATIONS. 

Another  man  was  wounded  by  a  small  sword  in  the  same 
joint;  he  was  carried  to  the  hospital  de  la  Charite.  On  examin- 
ing the  wound,  it  was /bund  that  the  capsule  of  the  joint  was 
opened.     This  wound  healed  like  the  most  simple  puncture. 

As  the  practitioners  of  all  ages  have  agreed  in  referring  the 
danger  of  wounds  of  the  joints  to  the  admission  of  air,  the  fa- 
cility with  which  pundlured  wounds  of  the  articulations  heal, 
may  be  accounted  for  from  the  narrowness  of  the  wound,  and 
the  difficulty  opposed  to  the  insinuation  of  air.  But  experience 
also  proves,  that  wounds  of  the  joints,  by  cutting  instruments, 
are  not  very  dangerous,  though  the  admission  of  air  into  them 
is  manifest. 

A  Alassacreur  of  the  second  of  September,  who  seized  by  the 
hair  a  prisoner  of  the  Abbaye  Saint  Germain^  received  on  his  wrist 
the  blow  levelled  at  the  head  of  the  victim.  The  posterior  part 
of  the  articulation  was  entirely  opened,  and  the  convexity  for- 
med by  the  scaphoides,  semilunaris,  and  pyramidalis,  aban- 
doned the  ends  of  the  bones  of  the  fore-arm.  He  was  admit- 
ted into  the  hospital  cle  la  Charite ;  the  lips  of  the  wound  were 
immediately  brought  together  j  the  hand  wr.s  kept  much  ex- 
tended by  means  of  a  splint  •<,  the  skin,  tendons  of  the  extensor 
muscles,  and  the  capsules,  all  healed  by  the  first  intention,  and, 
at  the  end  of  twelve  days,  he  was  discharged,  quite  cured. 

A  boy  employed  in  the  kitchen  of  the  hospital  de  la  Charitey 
had  the  articulation  of  his  wrist  opened  by  a  piece  of  a  vessel 
of  delph  ware ;  the  lips  of  the  wound  were  brought  together, 
and  the  patient  recovered  in  a  very  few  days. 

A  shoemaker's  v/ife  opened  with  a  sharp  cutting  instrument 
the  articulation  of  her  wrist  on  the  external  side,  for  about  one 
third  of  its  circumference ;  the  tendons  of  the  radiales  externi, 
extensores,  and  long  abduclor  of  the  thumb,  were  divided. 
Citizen  Boyer  was  called  in ;  he  closed  the  wound,  which 
healed  by  the  first  intention,  and  was  cicatrized  on  the  third 
day. 

The  facility  with  Avhich  tlie  incisions  made  in  the  joints  for 
the  purpose  of  extracting  foreign  bodies,  heal,  proves  also,  that 
wounds  of  the  articulations  are  not  attended  with  so  much  dan- 
ger as  has  been  generally  supposed.  But  though  the  fa£ts 
just  related,  fully  invalidate  the  opinions  of  the  ancients,  yet  it 
must  be  allowed  that  such  a  happy  termination  does  not  always 
take  place.  Cases  sometimes  occur,  in  which  the  wound  is 
followed  by  a  violent  inflammation  that  terminates  in  gangrene, 
or  lays  the  foundation  of  a  caries  of  the  ends  of  the  bones. 


OF    WOUNDS    OF    THE    ARTICULATIONS.  2^9 

These  melancholy  consequences,  as  tlie  ancients  have  well  ob- 
served, seem  to  be  brought  about  by  the  contaft  of  air,  which 
excites  an  inflammation  of  the  synovial  membrane.  But  tliat 
this  cause  can  produce  these  effefts,  it  must  be  continued  for 
some  time,  and  must  make  a  considerable  impression  on  the 
capsule  and  cartilages.  The  imprudent  application  of  charpie, 
or  any  other  dressing,  to  the  surfaces  of  the  joint,  produces  still 
more  dangerous  consequences.  A  man  received  a  sabre-wound 
on  the  external  side  of  the  wrist,  which  opened  the  articula- 
tion; he  was  brought  to  the  hospital  de  la  Charlie;  one  of  the 
monks,  who  then  dire£led  that  institution,  filled  the  wound 
with  charpie ;  an  enormous  swelling  took  place,  gangrene  su- 
pervened, and  the  patient  died. 

The  danger  is  equally  great  when  the  wound  suppurates ;  the 
purulent  matter,  formed  in  the  joint,  irritates  the  parts^  and 
causes  an  exfoliation  of  the  cartilages,  or  caries  of  the  ends  of 
the  bones.  These  consequences  are  also  to  be  apprehend  when 
the  wounding  instrument  has  not  only  penetrated  into  the  joint,  ' 
but  wounded  the  cartilages,  or  ends  of  the  bones.  A  young 
man  received  a  sabre-wound  in  the  anterior  and  external  part 
of  the  knee,  which  entirely  divided  the  patella;  the  lips  of  the 
wound  were  brought  exadtly  together ;  but  a  great  swelling  came 
on,  and  excluded  every  hope  of  union  by  the  first  intention.  The 
dressings  were  taken  off,  the  parts  were  covered  with  a  cata- 
plasm, and  the  patient  was  bled  ;  but  the  swelling  continued  to 
increase,  an  abscess  formed  above  the  patella,  between  the 
femur  and  the  triceps  cruralis,  and  the  entire  limb  became 
much  swelled.  Death  soon  ensued,  and,  on  disscftion,  the 
patella  was  found  divided,  and  the  cartilages  partly  disorgan- 
ized. 

Another  young  man  received  in  a  duel  a  sabre-v/ound  on 
the  anterior  part  of  the  point  of  the  shoulder,  which  opened 
the  articulation  of  the  humerus  with  the  scapula,  and  divided 
the  end  of  the  clavicle  next  the  scapula,  the  deltoid  muscle, 
and  a  portion  of  the  great  perioral  muscle.  The  wound  was 
immediately  dressed  by  bringing  its  sides  together,  but  a  hae- 
morrhage came  on  the  third  day,  which  made  it  necessary  to 
remove  the  dressing.  The  vessel  was  too  deep-seated  to  be 
discovered  and  taken  up ;  an  attempt  was  made  to  stop  the  he- 
morrhage by  stuffing  the  wound,  after  which  a  violent  inflam- 
mation supervened,  which  terminated  in  the  formation  of 
enormous  abscesses.  The  patient  died,  and  the  articulation 
was  found  full  of  pus. 


300  OF    WOUNDS    OF    THE    ARTICULATIONS. 

A  young  man,  aged  eighteen  years,  received  a  sabre-wound 
in  the  inferior  part  of  the  left  arm  -,  the  weapon  came  obUquely 
from  above  downwards,  and  cut  off  entirely  the  external  con- 
dyle of  the  OS  humeri.  The  wound  was  not  dressed  for  two 
days  after  the  accident,  at  which  time  he  was  brought  to  the 
hospital  de  la  Charite ;  the  divided  parts  were  now  brought  to- 
gether, but  the  swelling  soon  obliged  us  to  relax  the.strips  of  ad- 
hesive plaster;  emollients  were  applied;  pus  and  synovia  flowed 
abundantly  from  the  wound,  especially  when  pressure  was  made 
on  the  sides  of  the  articulation ;  abscesses  formed  j  the  fever 
assumed  a  bad  aspect;  the  swelling  extended  to  the  whole  of 
the  limb,  and  the  patient  was  on  the  point  of  dying;  amputa- 
tion of  the  arm  was  now  had  recourse  to,  by  which  the  pa- 
tient's life  was  saved.  On  opening  the  articulation,  the  soft 
parts  surrounding  it  were  distended  with  pus,  the  joint  itself 
was  filled  with  a  fetid  purulent  matter,  the  cartilages  were 
nearly  destroyed,  and  the  head  of  the  radius  was  somewhat 
carious. 

What  inferences  are  we  to  deduce  from  all  these  fadts  ap- 
parently contradi6lory  ^.  What  prognosis  are  we  to  form  in 
wounds  of  the  articulations  .■'  What  treatment  is  adapted  to 
them  .''  The  prognosis  must  be  necessarily  doubtful ;  it  is  fa- 
vourable, when  the  wounded  joint  is  superficial,  the  wound  in 
the  integument  and  capsule  not  extensive,  and  consisting  of  a 
simple  incision  without  contusion ;  when  no  vessel  is  opened, 
or  principal  nerve  wounded ;  and,  lastly,  when  with  these  fa- 
vourable circumstances  the  admission  of  air  has  been  prevented 
by  quickly  closing  the  wound. 

The  principal  indications  of  cure  are,  to  bring  the  divided 
parts  into  contact,  to  exclude  the  air,  remove  foreign  sub- 
stances, and  keep  the  limb  free  from  every  thing  that  might  ex- 
cite inflammation.  When  this  practice  is  not  successful,  we  must 
combat  the  inflammation,  open  the  abscesses,  prevent  the  stag- 
)iation  of  the  pus  by  making  counter-openings ;  and,  lastly, 
amputate  the  limb,  when  preserving  it  brings  the  patient's  life 
in  danger. 


-JO  I 


CHz\PTFR  XX. 


OF  WHITE  SWELLINGS  OF  THE  JOINTS. 

THE  name  of  lymphatic  tumour,  or  white  swelling,  has 
been  given  to  swellings  of  the  joints,  unaccompanied 
with  symptoms  of  inflammation.  Such  is  the  definiiion  of 
them  given  by  Bell  in  a  Dissertation  on  White  Swellings,  at 
the  end  of  his  Treatise  on  Ulcers.  In  fa^V,  an  increased  heat 
and  discoloration  of  the  skin  are  never  observed,  at  least  in  the 
beginning  of  these  swellings ;  there  is  simply  a  tum.efaclion  of 
the  part,  with  pain  more  or  less  deep  seated.  The  English 
author  just  mentioned  has  very  justly  marked  out  two  principal 
varieties  of  this  disease. 

In  the  first,  called  rheumatic,  the  patient  feels  dull  pains  in 
the  whole  of  the  limb,  before  the  appearance  of  the  tumour, 
which  h  often  a  critical  termination  of  rheumatism.  The  pain 
now  becomes  fixed  in  the  joint,  and  diminishes  in  violence ; 
the  soft  parts  surrounding  the  articulation  swell  more  or  less  ; 
but  there  is  no  change  in  the  colour  of  the  skin,  nor  is  there 
an  increase  of  heat.  If  the  disease  be  seated  in  the  knee,  the 
patient  keeps  the  leg  more  or  less  bent,  in  order  to  relieve  pain  ; 
the  muscles,  tendons,  and  even  soft  parts,  from  remaining  in 
this  contracted  state,  become  stiff,  and  hence  results  contrac- 
tion or  rigidity  of  the  limb,  or  even  a  complete  anchylosis. 
The  pains  increase  by  degrees,  the  swelling  augments  and  dis- 
tends the  skin  ;  inflammation  takes  place,  which  terminates  in 
suppuration,  and  the  formation  of  abcesses  in  the  cellular  sub- 
stance ;  these  burst  spontaneously,  and  leave  fistulous  openings. 
Through  these  fistulx  flows  a  whitish  or  serous  matter,  at  first 
inodorous,  but  it  is  soon  vitiated  by  the  contact  of  air,  and  be- 
comes fetid.  The  disease  extends  its  ravages  from  the  soft 
parts  to  the  cartilages  and  ends  of  the  bones.  The  leg  is  con- 
siderably diminished  in  si^e  ;  this  may  depend  on  the  impedi- 
ment to  the  distribution  of  the  fluids,  bv  the  pressure  made  on 
the  vessels   by  the  enlarged  and  indurated  parts,  or  rather  on 


302         OF    WHITE    SWELLINGS    OF    THE    JOINTS. 

the  swelled  joint  drawing  to  itself  most  part  of  the  fluids,  and 
thus  diminishing  the  quantity  which  should  go  to  nourish  the 
leg.  The  immobility  of  the  limb  tends  also  to  diminish  the 
nutrition  of  the  leg,  since  it  is  found  that  the  emaciation  ex- 
tends to  the  inferior  part  of  the  thigh.  The  skin,  excessively 
distended,  becomes  inflamed  and  ulcerated  ;  the  veins  become 
varicose,  and  burst ;  and  the  patient,  exhausted  by  the  conti- 
nuation of  pain,  and  the  absorption  of  purulent  matter,  drags 
on  a  miserable  existence  for  some  time,  and  dies. 

The  course  of  the  disease  is  described  here  as  it  takes  place 
in  the  knee,  which  is  its  most  usual  seat  ;  but  the  articulations 
of  the  elbow,  hip,  wrist,  and  foot,  are  by  no  means  exempt 
from  it. 

On  dissciStlng  the  diseased  joint,  the  soft  parts  are  found  in- 
durated, decomposed,  and  in  a  confused,  greyish  mass,  some- 
what resembling  lard.  The  swelled  ligaments  form  one  body 
with  the  cellular  substance  j  the  cartilages  preserve,  in  some 
cases,  their  natural  colour  •,  in  others,  especially  when  the  af- 
fe£lion  has  continued  long,  they  and  the  ends  of  the  bones  are 
affected  with  caries.  The  cellular  tissue  placed  behind  the  infe- 
rior ligament  of  the  patella,  between  the  femur  and  the  tendon 
of  the  extensors  of  the  leg,  in  the  ham,  and  behind  the  cross 
ligaments  of  the  knee  in  the  interval  between  the  condyles  of 
the  femur,  has  also  the  colour,  appearance,  and  consist- 
ence of  lard.  In  some  cases,  collefiions  of  a  bad  purulent 
matter  are  found  in  different  parts  of  the  cellular  substance. 

The  white  swelling  produced  by  a  scrofulous  taint,  which 
establishes  itself  in  the  great  articulations,  has  sometimes  an 
appearance,  and  pursues  a  course  similar  to  that  just  described  ; 
at  other  times  dull,  deep-seated,  and  circumscribed  pains  pre- 
cede it,  and  announce  its  formation.  The  swelling  is  at  first 
scarcely  perceptible,  and  when  it  becomes  more  considerable, 
it  is  perceived,  that  it  arises  almost  entirely  from  an  augmenta- 
tion of  volume  in  the  ends  of  the  bones,  and  that  the  integu- 
ments scarcely  participate  in  the  morbid  state.  The  limb  be- 
comes emaciated  and  contrafled,  the  pain  appears  confined  to 
the  centre  of  the  joint,  and  to  the  extremities  of  the  bones ; 
emollient  and  anodyne  applications  neither  appease  the  pain, 
nor  produce  a  resolution  of  the  swelling ;  lastly,  the  patient, 
exhausted  by  his  suS^erings,  perishes.  On  opening  the  knee, 
every  part  is  found  in  a  natural  state,  except  the  cartilages,  and 
ends  of  the  bones,  which  are  ailedled  with  caries. 


OF    WHITE    SWELLINGS    OF    THE    JOINTS.  303 

It  would  be  too  tedious  to  describe  the  different  forms  under 
which  this  disease  may  present  itself ;  after  pointing  ont  its  two 
principal  varieties,  it  will  be  sufficient  to  remark,  tlv.it  it  dif- 
fers so  much  in  different  individuals,  that  it  is  scarcely  accom- 
panied by  the  same  symptoms  in  two  patients. 

White  swellings  are  sometimes  produced  by  rheumatic  affec- 
tions ;  but  most  generally  they  originate  from  a  scrofulous  taint. 
They  seldom  appear  to  be  produced  by  an  external  cause, 
hough  they  s  ometimes  follow  strains  that  have  been  neglected, 
or  badly  treated,  and  fradlures  in  the  neighbourhood  of  the 
joints.  Sometimes  the  swelling  comes  on  rapidly  without  any 
apparent  cause.  Such  was  the  case  of  a  young  man,  whose 
arm  I  have  lately  amputated  for  a  white  swelling,  and  caries  of 
the  elbow  joint.  Lastly,  a  blow,  fall,  or  any  external  violx?nce, 
may  produce  the  swelling  in  a  scrofulous  person,  in  whom  the 
cause  of  the  disease  seems  to  be  easily  called  forth. 

The  enlargement  of  the  ends  of  the  phalanges,  considered 
by  some  authors  as  a  species  of  spina  ventosa,  belongs  to  the 
class  uf  white  swellings.  This  disease,  as  has  been  already  ob- 
served, affefts  both  the  substance  of  the  bones  and  their  arti- 
culations. 

The  prognosis  is  always  unfavourable,  whatever  may  be  the 
age  or  constitution  of  the  patient,  the  cause  or  duration  of  the 
disease.  The  tumours  are  very  seldom  discussed  ;  they  almost 
uniformly  resist  the  numerus  remedies  with  v/hich  they  are 
combated.  In  some  fortunate  cases,  the  disease,  arrived  at  a 
certain  pitch,  makes  no  further  progress  ;  the  pains  diminish, 
and  in  time  disappear  ;  the  limb  remains  contracted  ;  the  ends 
of  the  bones  grow  to  one  another,  and  the  patient  escapes 
death,  but  has  an  anchylozed  joint. 

In  the  greater  number  of  cases,  the  patient,  harassed  by  vi- 
olent pains,  is  exhausted  by  the  copious  suppuration,  he6tic  fe- 
ver, and  colliquative  diarrhoea,  and  no  resource  is  left  but  the 
amputation  of  the  afie<rted  parts.  The  prognosis  is  somevv^hat 
less  unfavourable  in  cases  of  children  who  have  not  yet  attained 
the  age  of  puberty.  This  period,  so  favourable  for  the  cure 
of  scrofula,  brings  about  also  that  of  white  swellings,  by  de- 
stroying the  evil  which  is  its  most  frequent  cause. 

The  diseases  the  most  difncult  to  cure,  are  those  in  which 
the  greatest  number  of  remedies  have  been  u;ed  ;  we  must  not 
then  bc-astonished  at  the  multiplicity  of  means  proposed  for  the 
cure  of  white  swellings.     These,  v/hether  adopted  on  rational 


304  OF    WHITE    SWELLINGS    OF    THE    JOINTS. 

principles,  or  recommended  empirically,  must  be  adapted  to 
the  variety  of  the  disease,  and  the  stage  in  which  it  exists. 

The  limb  must  be  kept  perfectly  at  rest :  without  this  pre- 
caution, the  remedies  cannot  produce  any  good  effect ;  for  the 
motion  of  the  affe<fted  parts  augments  the  primary  cause  of  the 
disease.  Thus,  in  white  swellings  of  the  knee,  the  patient 
should  remain  in  bed,  with  his  leg  as  much  extended  as  the 
pains,  and  tendency  which  he  has  to  bend  it,  will  permit.  If 
he  be  young  and  vigorous,  and  if  an  external  cause  has  produ- 
ced the  disease,  or  contributed  to  its  developement,  or  if  it 
has  been  occasioned  by  a  rheumatic  affection,  some  blood  may 
be  taken  away  in  the  beginning  of  the  disease.  The  aliments 
should  be  mild,  and  taken  in  small  quantities  at  a  timej  the 
drinks  should  be  refrigerant  and  copious ;  and  the  diseased 
joint  should  be  covered  with  an  emollient  cataplasm,  which  is 
to  be  renewed  twice  a  day.  Such  are  the  means  for  subduing 
the  inflammation  which  is  in  some  degree  latent  in  the  joint ;  to 
these  may  be  joined  the  application  of  leeches,  or  even  scarifi- 
cations, v/hich  Bell  prefers,  and  by  which  he  says  we  may  draw- 
away  at  once  eight  or  ten  ounces  of  blood.  When  the  pains 
diminish,  and  the  tumour  tends  to  a  resolution,  the  emollients 
are  rendered  somewhat  repellent ;  a  cataplasm  made  of  the 
root  of  briony  boiled  in  milk  may  then  be  applied  with  advan- 
tage. Black  soap,  brought  to  the  consistence  of  a  liniment 
by  means  of  camphorated  spirit  of  wine,  has  been  also  em- 
ployed with  some  benefit.  Fri;Slions  about  the  knee,  with  a 
volatile  liniment,  composed  of  an  ounce  of  oil  and  half  an  ounce 
of  ammonia,  have  been  found  useful.  The  joint  is  to  be  rubbed 
tv.'ice  a  day  with  this  liniment,  and  afterwards  covered  with  a 
piece  of  fine  linen  that  has  been  soaked  in  the  same  substance. 

Mild  laxatives,  such  as  tamarinds,  cream  of  tartar,  dissolved 
in  whey,  or  different  laxative  salts  dissolved  in  veal  broth, 
are  to  be  administered  at  the  same  time.  They  cause  a 
determination  of  the  fluids  to  the  intestines,  and  thus  divert 
them  ffom  the  diseased  articulation.  Lastly,  when  the  ir- 
ritation and  inflammation  are  abated,  the  most  active  resol- 
vents are  to  be  used.  Blisters  are  then  applied  to  the  articula- 
tion, and  sometimes  the  blistered  surface  is  made  to  suppurate, 
and  the  dischartje  is  kept  up  by  a  stimulating  ointment.  Bell 
recommends,  strongly,  friftions,  with  mercurial  ointment,  which 
have,  he  says,  the  double  advantage  of  introducing  into  the 
system  a  powerful  solvent,  and  increasing  the  adlion  of  the  skin. 
They  are  to  be  frequently  repeated  every  day,  and  continued 
until  the  m.outh  is  gently  afFecled. 


OF    WHITE    SWELLINGS    OF    THE   JOINTS.  305 

Le  Dran,  and  many  other  pratflitioners,  have  advised  to 
pump  warm  water  on  the  affe(Sled  joint.  To  derive  from  this 
praftice  its  full  efi'eft,  the  water  must  fall  from  an  elevated  place, 
be  used  as  warm  as  the  patient  can  bare  it,  and  be  rendered 
stimulant  by  a  neutral  salt,  or  an  alcali,  dissolved  in  it.  It  is  in 
this  way  that  pumping  is  used  in  the  hospital  Saint  Louis, 
which  contains  a  greater  number  of  patients  labouring  under 
white  swellings  than  any  other  hospital  in  Paris.  The  mineral 
waters  of  Bareges  and  fiourbonne,  &c.  may  be  used  in  a  similar 
maimer.  Warm  baths,  of  a  diluted  alcaline  solution,  anjj  va- 
pour barhs  of  the  same  solution,  have  been  recommended. 
Much  benefit  is  said  to  be  derived  from  a  kind  of  animal  bath 
used  in  the  following  manner,  the  patient  introduces  the  af- 
fected joint  into  an  opening  made  in  the  belly  of  an  animal  re- 
cently killed,  and  keeps  it  for  some  time  among  the  warm  in- 
testines. The  mild  temperature  and  un^luosity  of  this  bath, 
produces  an  effedl  similar  to  that  obtained  by  folding  the  omen- 
tum of  a  sheep  round  the  joint,  as  recommended  by  Bell. 

Very  violent  means,  such  as  the  adtual  cautery,  and  burn- 
ing with  moxa,  often  produce  a  diminution  of  the  swelling ; 
but  some  enlargement  still  remains,  and  the  pain  becomes  in- 
tense. By  such  powerful  stimulants,  the  state  of  the  patient 
is  rendered  more  distressing,  his  disease  is  aggravated,  and  its 
progress  is  accelerated. 

When  the  treatment  is  successful,  the  joint  remains  for  a 
length  of  time  incapable  of  motion,  and  very  often  anchylo- 
zed.  But  the  incapability  of  motion  must  not  be  always  consi- 
dered as  a  certain  mark  of  anchylosis ;  it  often  depends  only  on 
the  stiffness  of  the  soft  parts,  and  particularly  of  the  tendons. 
This  may  be  remedied  in  time,  by  moving  the  limb  every  day, 
and  gradually  increasing  the  motion ;  and  by  the  use  of  warm 
baths,  pumpings,  and  fomentations.  However,  all  interference 
whatever  should  be  abstained  from,  when  there  is  a  suspicion 
that  the  ends  of  the  bones  are  unsound,  or  anchylozed  ;  endea- 
vours to  move  the  limb,  in  such  cases,  would  cause  so  much  ir- 
ritation as  to  reproduce  the  primary  affeftion. 

In  cases  where  the  white  swelling  is  evidently  scrofulous,  the 
antiphlogistic  plan  cannot  be  pursued  5  tonics  and  corroborants 
are  then  to  be  administered,  with  which  may  be  combined  the 
application  of  solvent  and  stimulant  plasters,  such  as  the  soap 
plaster,  that  of  cicuta,  &c.  &c.  Often  in  these  cases,  as  ia 
the  preceding,  however  assiduous  and  rational  the  treatment, 
the  swelling  continues  to  increase  \  at  first,  hard  and  elastic  in 
39 


3C6  OF    WHITE    SWELLINGS    OF    THE    JOINTS. 

Some  places,  It  soon  points,  and  a  fludluation  is  felt  in  It ;  ab- 
scesses burst  spontaneously,  and  their  openings  degenerate  into 
fistulse. 

Some  empirics  have  been  daring  enough  to  Irritate  the  tu- 
mour with  acrid  and  stimulating  applications,  in  order  to  con- 
vert the  languid  swelling  into  a  phlegmon,  and  afterwards  ob- 
tain a  termination  of  it  either  by  resolution  or  suppuration. 
Fabricius  ab  Aquapendente  mentions  a  case  of  this  kind,  in 
which  a  charlatan  enveloped  the  knee  with  a  synapism  of  a  very 
acrid  vegetable.  An  a£live  Inflammation  took  place,  which, 
combated  in  the  ordinary  way,  terminated  by  resolution ;  and 
the  patient  recovered  the  entire  use  of  his  knee.  But  this 
case  cannot  serve  as  a  rule  ;  In  the  greater  number  of  Instances 
in  which  a  similar  treatment  would  be  followed,  It  would  infal- 
libly accelerate  the  progress  of  the  swelling,  and  caries  of  the 
ends  of  the  bones,  increase  the  sufFerjngs,  and  hasten  the 
death  of  the  patients. 

When  there  are  many  abscesses  about  the  joint,  and  the  col- 
ledllons  of  pus  are  considerable.  It  is  necessary  to  prevent  the 
stagnation  of  this  fluid,  and  the  absorption  of  it,  by  enlarging 
the  fistulous  openings,  and  renewing  the  dressings  repeatedly. 
It  is  sometimes  useful  in  these  cases  to  pass  a  seton  in  the  fistu- 
•  lous  passage.  This  favours  the  escape  of  the  purulent  matter, 
and  Impedes  the  introduclion  of  the  air.  If  the  pains  be  pe- 
netrating and  excessive,  their  intensity  may  be  diminished  by 
the  external  and  internal  use  of  sedatives  and  opiates ;  but 
when  they  are  not  appeased  by  these  remedies,  but  become 
more  intolerable,  and  take  away  the  patient's  rest ;  and  when 
hecHiic  fever,  a  constant  diarrhoea,  and  colliquative  sweats, 
bring  on  marasmus,  and  endanger  the  patient's  life,  the  am- 
putation of  the  limb,  the  last  resource  in  such  an  invincible 
disease,  must  be  had  recourse  to.  We  must  not,  however, 
be  In  too  great  a  hurry  to  perform  this  operation,  le^f  the  pa- 
tient accuse  us  of  precipitance  in  taking  away  a  limb  which 
might  be  preserved.  Besides,  a  state  of  debility  is  extremely 
favourable  for  most  surgical  operations,  and  for  amputations  In 
particular.  It  obviates  violent  Inflamnratlon,  the  troublesome 
consequence  of  every  operation  in  which  a  great  number  of  sen- 
sible organs  are  concerned.  However,  we  do  not  understand, 
by  a  state  of  debility,  that  state  in  which  the  patient  Is  exhaust- 
'  ed  and  harassed  by  the  continuance  of  the  disease,  diarrhoea, 
and  colliquative  sweats.  Bell  appears  to  recommend  deferring 
the  operation  until  this  state  of  exhaustion  has  taken  place.     A 


OF    WHITE    SWELLINGS    OF    THE    JOINTS.  307 

dangerous  precept.  If  observed,  the  patient,  consumed  by 
marasmus,  will  be  no  more  able  to  furnish  organic  aftiou  suf- 
ficient for  the  healing  of  such  a  wound  as  results  from  amputa- 
tion. 

In  order  to  determine  on  the  necessity  or  Impropriety  of  this 
operation,  the  state  of  the  patient  must  be  attentively  examined, 
the  resources  of  nature  considered,  and  what  is  to  be  fear- 
ed, and  what  may  be  hoped  for,  maturely  weighed.  If  the 
disease  is  recent ;  if  no  suppuration  has  yet  taken  place  •, 
if  the  pains  are  supportable  j  and  if  the  patient  preserves  his 
plumpness  and  vigour,  the  use  of  the  means  likely  to  produce 
a  resolution  of  the  swelling  is  to  be  persisted  in.  It  would  be 
contrary  to  all  rule  to  amputate  In  this  case ;  for,  on  the  one 
hand,  the  violence  of  the  Inflammatory  symptoms  Is  to  be 
dreaded  j  and,  on  the  other,  the  cause  of  the  disease  Inherent 
In  the  solids,  and  diffused  in  the  fluids,  has  not  yet  fixed  itself 
entirely  in  the  joint.  We  must  therefore  defer  operating  until 
it  is  firmly  established  in  the  articulation  ;  and  until,  consumed, 
as  it  were,  by  the  produ£lion  of  the  disease.  It  Is  rendered  In- 
capable of  changing  Its  situation,  or  taking  a  new  residence  In 
another  joint.* 

Lastly,  the  operation  Is  not  to  be  performed  but  In  cases 
where  one  joint  only  Is  affefted  ;  If  many  articulations,  the 
knee  and  elbow  for  instance,  are  attacked,  we  must  not  think 
of  operating.  "  In  reality.  It  Is  doubtful  If  death  be  not  prefer- 
able to  the  mutilation  that  would  result  from  such  operations  -, 
besides,  the  danger  attending  them  would  diminish  very  much 
the  probability  of  their  success.  It  Is,  then,  only  in  affedlions 
of  the  small  joints,  such  as  the  phalanges,  that  the  different 
parts  can  be  extirpated.  When  many  of  the  principal  articu- 
lations are  affeiSted  at  the  same  time,  and  the  disease  is  advanced, 
death  is  Inevitable. 

A  pradlice  less  terrifying  than  amputation.  Inasmuch  as  it 
does  not  deprive  the  patient  of  his  limb,  has  been  proposed  in 
cases  of  white  swelling.  It  consists  in  cutting  off,  or  extirpa- 
ting, the  carious  extremities  of  the  bones,  when  the  state  of 
the  soft  parts  admits  It. 

•  How  will  the  physiologists  of  this  country  receire  this  reasoning  ?  It  Is 
evidently  founded  on  the  doftrine  of  the  humoral  pathologists.  It  may  be 
asked,  what  evidence  is  there,  that  the  cause  (in  the  opinion  of  tlie  author) 
so  firmly  fixed  in  the  solid?,  and  widely  diffused  in  the  fluids,  abandons 
its  spacious  residence  to  confine  itself  in  a  single  joiAt  ?  and  why  the  solids 
and  fluids  do  not  manifest  some  appearance  of  its  having  deserted  them  ? 
^  Translator. 


308  OF    WHITE    SWELLINGS    OF    THE    JOINTS. 

This  operation  is  practicable  only  in  cases  where  the  affec- 
tion is  confined  to  the  ends  of  the  bones,  and  extends  but  vtry 
little  to  the  soft  parts.  If,  for  instance,  the  cellular  tissue  and 
ligaments  about  the  knee  are  swelled,  and  coll^fted  into  a  ho- 
mogeneous lardy  mass,  no  person  would  think  of  performing 
it.  It  is,  then,  confined  to  cases  in  "which  the  bones  only  are 
affefted.  In  an  affeftion  thus  limited,  which  isjjy  no  means 
frequent,  the  ends  of  the  bones  are  cut  off  in  this  wav. 

If  the  head  of  the  humerus  be  diseased,  which  is  ascertained 
by  an  attentive  examination  of  the  tumour,  and  particularly  by 
the  introduction  of  a  probe  through  the  fistulae  which  commu- 
nicJite  with  the  articulation,  the  operation  is  commenced  by  ma- 
king on  the  external  and  upper  part  of  the  arm  two  longitudi- 
nal incisions^  directed  obliquely  downwards,  and  distant  frotn 
one  another  about  two  iuches  at  their  superior  part,  but  ap- 
proaching as  they  descend^  and  uniting  in  the  form  of  a  large 
V,  A  triangular  flap  formed  of  the  skin  and  deltoid  muscle, 
is  preserved  in  this  way.  It  is  disse^ed  and  raised  upwards  by 
detaching  the  muscle  from  the  superior  and  external  part  of  the 
humerus  ;  it  is  then  committed  to  an  assistant,  and  the  surgeon 
bringing  the  elbow  forwards  and  inwards  with  his  left  hand, 
cuts  the  orbicular  ligament  of  the  articulation  with  his  right  : 
the  ligament  is  made  tense  by  the  direction  given  to  the  arm 
by  this  motion  of  the  elbow.  The  tendons  of  the  subscapula- 
ris,  infraspinatus,  supraspinatus,  and  teres  minor,  are  to  be 
cut  at  the  same  tinje  :  this  being  done,  the  head  of  the  hume- 
rus is  easily  luxated  upwards  and  outwards,  without  cutting 
the  tendons  of  the  peftoralis  major,  latissimus  dorsi,  and  teres 
major,  which  has  been  recommended,  but  which  could  not  be 
done  without  danger,  of  wounding  the  brachial  vessels  and 
nerves.  The  head  of  the  humerus  being  thus  luxated,  the  ex- 
tent of  the  caries  is  ascertained  ;  next,  the  glenoid  cavity  of  the 
scapula  is  examined,  in  order  to  discover  if  it  be  afFe6ted  ;  a 
plate  of  lead  or  piece  of  pasteboard  is  then  placed  under  the 
head  of  the  humerus  to  protect  the  soft  parts,  and  the  carious 
portion  of  the  latter  bone  is  sawed  off.  During  the  adt  of  saw- 
ing, an  assistant  prevents  the  humerus  from  descending,  and 
at  the  same  time  keeps  it  fixed  and  motionless. 

The  circumflex  artery  is  the  only  vessel  to  be  taken  up  in  this 
operation;  it  is  found  at  the  posterior  and  superior  part  of  the 
triangular  flap. 

The  extirpation  of  the  head  of  the  humerus  was  first  prac- 
tised by  Wlxite;  the  patient  recovered  in  four  months,  and 


OF    WHITE    SWELLINGS    OF    THE    JOINTS.  3C9 

his  arm,  shorter  by  nearly  two  inches,  preserved  its  shape  and 
strength.  Bent,  of  Newcastle,  as  he  relates  in  the  sixty-fourth 
volume  of  the  Philosophical  Trafisaflionsy  performed  soon  after- 
wards the  same  operation.  Since  this  period,  many  English 
surgeons  say  they  have  performed  it.  Vigarous,  of  Montpellier, 
has  also  given  a  case  of  it  in  a  Memoir  presented  to  the  Acade- 
my of  Surgery  in  1774-. 

Park,  a  surgeon  of  Liverpool,  conceived  and  executed  the 
bald  project  of  extending  to  the  articulations  of  the  knee  and 
elbow,  the  operation  performed  on  the  humerus  by  White. 
But  in  these  cases,  the  circumstances  are  much  more  unfavour- 
able, and  the  cutting  off"  the  ends  of  the  bones  much  more 
difficult.  Nevertheless,  Park  has  performed  the  operation  with 
success,  on  the  knee  of  a  man  thirty-three  years  of  age,  and  of 
a  robust  constitution.  This  surgeon  made  two  parallel  inci- 
sions along  the  sides  of  the  patella,  which  extended  to  two 
inches  above,  and  two  below  this  bone  •,  one  of  the  articular 
arteries  was  divided  and  taken  up;  a  transverse  incision  was 
made  at  two  inches  above  the  joint,  and  another  at  two  inches 
below  it ;  one  comprised  the  half  of  the  thickness  of  the  thigh, 
the  other,  half  of  that  of  the  leg ;  all  the  anterior  ligaments 
were  cut,  and  the  patella  was  removed,  after  which  a  knife  was 
insinuated  behind  the  femur,  to  separate  the  flesh  from  the 
bones,  to  the  extent  of  about  four  inches.  The  edge  of  the 
knife  was  kept  close  to  the  posterior  part  of  the  bones,  in  order 
to  avoid  wounding  the  popliteal  vessels  and  nerves.  The  inci- 
sion behind  the  bones  being  thus  made,  a  plate  of  lead,  or  a 
large  spatula,  was  introduced  into  it,  in  order  to  prote£l  the 
vessels  and  nerves  of  the  ham  from  the  saw.  In  this  case  two 
inches  were  cut  from  the  femur,  and  one  inch  from  the  tibia; 
the  bones  were  then  replaced,  their  ends  brought  into  contaft, 
and  the  angles  of  the  wound  were  closed  by  a  few  stitches. 
The  disagreeable  symptoms  that  succeeded  were  numerous  and 
distressing,  notwithstanding  the  relaxed  state  of  the  soft  parts; 
however,  in  about  four  months  the  patient  was  able  to  walk. 
The  ends  of  the  bones  grew  together  ;  the  knee  was  turned 
outwards;  the  limb,  shortened  by  three  inches,  supported  the 
weight  of  the  body  very  well ;  and  the  patient  could  walk  with- 
out the  assistance  of  crutches. 

There  are  few  surgeons  intrepid  enough  to  undertake  a  si- 
milar operation.  The  lesion  of  the  popliteal  vessels  and  nerves, 
the  violence  of  inflammation,  and  an  abundant  suppuration. 


JIO  OF    ANCHYLOSIS. 

are  the  perils  to  which  a  patient  is  exposed,  to  preserve  a  limb 
always  deformed,  and  not  more  useful  than  a  wooden  leg. 

When  the  elbow  is  to  be  operated  on,  the  incisions  must  be 
made  on  the  posterior  side  of  the  joint,  as  the  principal  vessels 
and  nerves  are  placed  on  the  anterior  side.  As  to  the  rest,  the 
same  rules  are  to  be  observed  as  in  the  preceding  case. 


CHAPTER  XXI. 


OF  ANCHYLOSIS. 


ALL  affections  of  the  articulations,  which  consist  of  a  total 
or  partial  immobility  of  the  joint,  are  comprised  under 
the  general  denomination  of  anchylosis.  It  is  said  to  be  in- 
complete, when  there  is  only  a  stiffiiess  of  the  joint ;  and  com- 
plete, when  all  motion  is  impossible,  from  the  ends  of  the 
bones  growing  together.  It  is  further  distinguished  into  dry 
and  suppurating ;  but  the  last  is  a  symptom  of  white  swelling. 
Anchylosis  is  seldom  a  primary  disease,  it  almost  jlways  suc- 
ceeds to  another  complaint.  Thus  it  is  seen  to  take  place  after 
fra£lures,  particularly  when  in  the  neighbourhood  of  joints; 
after  sprains,  luxations  complicated  with  contusion,  or  badly 
reduced,  and  white  swellings,  &c.  &c.  Diseases  foreign  to 
the  bones,  such  as  an  aneurism  of  the  popliteal  artery,  or 
abscesses  formed  in  the  neighbourhood  of  a  joint,  may  occa- 
sion it.  In  a  word,  every  thing  that  keeps  a  joint  motionless, 
tends  to  produce  an  anchylosis,  and  one  so  much  the  more 
complete,  as  the  limb  remained  long  without  motion.  Anchy- 
losis from  ina£lion  appears  to  arise  from  the  gradual  diminution, 
or  even  total  cessation,  of  the  secretion  of  the  synovia.  It  is 
well  known  that  the  friftion  of  the  ends  of  the  joints  excites 
the  secretion  of  this  fluid. 


OF    ANCHYLOSIS.  JM 

One  may  conceive  the  possibility  of  a  complete  anchylosis 
taking  place  in  all  the  joints  of  the  body,  from  being  confined 
to  bed  for  a  length  of  time,  without  motion.*  The  secretion  of 
the  synovia  diminishes  gradually,  and  at  length  ceases  entirely; 
then  the  surfaces  of  the  joint,  deprived  of  this  fluid,  and  de- 
siccated, are  attacked  by  an  adiaesive  inflammation,  similar  to  that 
which  takes  place  in  the  pleura,  and  which  in  a  vast  number  of 
cases  occasions  an  adhesion  of  the  costal  portion  of  the  pleura 
to  that  covering  the  lungs.  The  ligaments,  tendons,  and  soft 
parts  surrounding  the  articulation,  acquire  during  the  inadlion, 
a  rigidity  which  is  difficultly  removed  ;  this  may  arise  from  the 
vital  power  of  the  parts  being  rendered  torpid  by  the  inadlivity; 
or  from  the  growing  together  of  the  different  parts  of  the  cel- 
lular substance ;  or  from  its  becoming  more  dense  from  the  in- 
spissation  of  the  lymph  and  fat  deposited  in  it. 

Haiving  said  so  much  on  the  formation  of  anchylosis,  let  lis 
see  what  is  the  influence  of  the  various  causes  which  produce  it. 
When  a  bone  is  fra^lured  in  the  neighbourhood  of  a  joint,  the 
limb  is  kept  motionless  by  the  apparatus,  during  the  whole  pe- 
riod of  ossification  or  union  of  the  ends  of  the  bonej  besides, 
the  inflammatory  swelling  which  coi^stantly  supervenes,  extends 
to  the  articulation,  and  attacks  the  ligaments,  capsule,  and  in 
general  all  the  surrounding  parts.  Sometimes  it  only  increases 
the  consistence,  thickness,  and  rigidity  of  these  parts  ;  at  other 
times  it  produces  a  mutual  adhesion  of  the  surfaces  of  the  joint, 
by  impeding  the  secretion  of  the  synovia.  This  is  one  of  the 
principal  reasons  for  reputing  fra^lures  of  bones  near  their  ex- 
tremities, more  dangerous  than  those  of  their  centre.  How- 
ever, the  latter  are  always  followed  by  more  or  less  stiffness  in 
the  articulations  of  the  fraflured  bone  ;  but  this  arises  from  the 
state  of  inacftivity,  in  which  the  limb  has  remained,  and  it  may 
be  removed  by  exercising  the  limb  gently,  and  increasing  the 
motion  gradually. 

The  stiffness  succeeding  to  fractures  has  been  for  a  long  time 
attributed  to  an  effusion  of  bony  matter  into  the  interior,  or 
cellular  substance  in  the  vicinity  of  the  joint.  This  mattei*, 
say  the  ancients  and  moderns,  is  a  kind  of  glue  which  unites 
more  or  less  completely  the  ends  of  the  bones,  and  at  the  same 
time  indurates  the  soft  parts.  This  theory,  which  is  found  in 
the  treatises  of  J.  L.  Petit  and  Duverney,  is  abandoned,  since 
the  existence  of  an  osseous  juice  is  rejected,  and  the  formation 

*  Noiiveaux  Elemens  de  Physiologie,  tome  il.  chap.  Des  Mcuvemens. 


312  Cf    ANCHYLOSIS. 

of  callus  in  fradlures  better  understood.  Besides,  disse<flions 
of  anchylozed  joints  have  never  discovered  the  osseous  concre* 
tions,  which  should  result  from  such  supposed  effusions.  The 
opinion,  that  a  change,  or  inspissation,  of  the  synovia,  was 
the  most  frequent  cause  of  anchylosis,  is  not  better  founded. 
On  dissecting  a  joint  in  which  a  complete  anchylosis  has  taken 
place,  the  ends  of  the  bones  are  found  united  at  one  point  j  and 
in  this  part  the  surfaces  have  lost  their  natural  polish ;  but  the 
parts  which  have  not  formed  an  adhesion,  preserve  their  polish, 
and  their  surfaces  are  lubricated  by  a  small  quantity  of  synovia, 
not  different  from  that  found  in  the  healthy  state. 

However  various  the  causes  of  anchylosis,  the  mode  in  which 
it  takes  place  is  always  the  same :  when  desiccated,  inflamed, 
and  sometimes  even  suppurating,  as  happens  in  some  white 
swellings  with  caries  of  the  ends  of  the  bones,  grow  together ; 
when  it  is  incomplete,  that  is  to  say,  when  it  consists  of  a  diffi- 
culty of  motion  in  the  part,  and  the  impossibility  of  perform- 
ing the  same  motions  as  in  the  healthy  state,  the  surfaces  of 
the  joint  are  still  contiguous,  and  the  disease  exists  only  in  the 
soft  parts  surrounding  the  articulation. 

It  is  essential  to  distinguish  these  tv/o  species,  since  the  first 
or  true  anchylosis  is  altogether  incurable,  and  is  to  be  consi- 
dered, in  most  cases,  a  happy  termination  of  a  grievous  disease. 
The  false  or  incomplete  anchylosis  is  rather  a  consequence  of 
disease,  than  a  primary  affection.  When  a  considerable  abscess 
takes  place  in  the  vicinity  of  a  joint,  for  instance  near  the  wrist 
or  joints  of  the  fingers,  the  destruction  of  the  cellular  substance 
occasions  a  stiffness  which  it  is  impossible  to  prevent  j  but  when 
the  tendons  exfoliate,  the  bones  to  which  they  are  attached  re- 
main motionless,  and  a  complete  anchylosis  inevitably  ensues. 
Therefore,  when  abscesses  form  near  the  joints  of  the  fingers, 
and  when  they  are  followed  by  exfoliation  of  the  tendons,  the 
fingers  should  be  bent,  in  order  that  they  may  anchyloze  in 
that  direction,  which  is  much  less  inconvenient  and  much  more 
favourable  for  the  various  uses  of  the  hand,  than  permanent 
extension.  On  the  contrary,  when  there  is  a  suspicion  that 
the  knee  will  remain  stiff,  after  the  operation  for  a  popliteal 
aneurism,  the  leg  must  be  kept  as  much  extended  as  the  pains 
will  permit.  The  same  conduCt  is  to  be  observed,  when,  after 
a  spontaneous  luxation  of  the  femur,  it  is  perceived  that  th« 
head  of  this  bone  will  attach  itself  to  the  pelvis,  and  that  the 
disease  will  terminate  by  anchylosis.  In  these  cases,  as  well 
as  in  every  other,  when  the  bones  are  grown  together,  even 


OF    ANCHYLOSIS.  31^ 

though  the  limb  may  have  a  bad  and  inconvenient  dlreftion,  it 
would  be  imprudent,  or  even  dangerous,  to  endeavour  to  de- 
stroy the  adhesions.  In  faft,  it  could  not  be  done  without 
using  considerable  violence  and  causing  great  pain,  and  would 
be  followed  by  inflammatory  symptoms  that  would  renew  the 
adhesion,  or  by  caries  of  the  bones,  which  might  occasion  the 
death  of  the  patient. 

When  the  false  or  incomplete  anchylosis  is  apprehended, 
measures  should  be  taken  to  prevent  it.     These  consist  in  mo- 
ving the  afFefted  limb  as  much  as  the  state  of  the  soft  parts  will 
permit.     This  precaution  is  much  more  necessary  in  afFeftions 
of  the  ginglymoidal  articulations,  than  in  those  of  the  orbi- 
cular, on  account  of  the   tendency  of  the  former,  from   the 
great  extent  of  their  surfaces,  the  multiplicity  of  their  ligaments, 
and  small  extent  of  motion,  to  become  anchylozed.     The  ex- 
ercise of  the  joint,  by  extending  the  contracted  soft  parts,  calls 
forth  their  vital  properties,  and  promotes  the  secretion  of  the 
synovia,  by  causing  a  fridlion  of  the  articulating  surfaces.     A 
crepitation,  arising  from  the  synovia  being  deticient,  is  first 
heard  ;  but  as  soon  as  this  fluid  is  secreted  in  greater  quantity, 
and  lubricates  the  surfaces  of  the  joint,  this  cracking  noise 
ceases.     A  certain  share  of  precaution  is  to  be  used  in  moving 
the  limb  j  the  motion,  if  rudely  performed,  might  cause  pain, 
and  induce  a  swelling  and  even  caries  of  the  ends  of  the  bones. 
It  is  by  proportioning  it  to  the  state  of  the  limb,  and  increasing 
daily  its  extent,  as  the  soft  parts  yield  and  grow  supple,  that 
good  effedts  can  be  derived  from  it.     The  exercise  of  the  joint 
is  not  to  be  left  to  the  patient  himself,  neither  is  it  to  be  con- 
fided to  ignorant  persons,  who  might  think  that  they  moved 
the  anchylozed  joint,  while  the  motion  took  place  in  the  one 
above  it.     It  is  thus  that  a  patient  labouring  under  a  stiffriess  of 
the  elbow,  if  dire«Sted  to  put  that  joint  frequently  in  motion, 
moves  the  entire  upper  part  of  the  arm,  by  making  the  hume- 
rus turn  in  its  articulation  with  the  scapula.     If  inflammation 
be  excited  by  these  attempts,  they  must  be  suspended  until  the 
inflammation  is  subdued,  and  not  recommenced  until  the  pain 
(eases.    We  are  often  obliged  to  use  considerable  force  in  elon- 
gating contradled  muscles,  and  it  is  to  the  great  violence  em- 
ployed in  such  cases  that  ignorant  bone-setters  are  often  in- 
debted for  their  success. 

The  efficacy  of  the  exercise  of  the  joint  is  increased,  and  its 
effe<Sls  seconded,  by  warm  baths,  emollient   applications,  by 
frictions  with  the  grease  of  fowls  and  other  animals,  nnd  espe- 
40 


J 14  OF    THE    DIVIATIONS    OF    BONES,    &C. 

cially  by  pouring  warm  water  on  the  part,  from  a  very  elevated 
situation.  Animal  baths,  and  the  other  means  mentioned  in 
the  chapter  on  white  swellings,  may  be  also  used.  When  all 
these  means  fail,  the  warm  waters  of  Bourbonne,  Bareges,  Spa, 
Bath,  and  Aix  in  Savoy,  or  other  warm  mineral  waters,  may 
be  had  recourse  to.  The  inconvenience  arising  from  the  dis- 
tance of  these  mineral  waters  is  now  happily  removed,  as  those 
that  are  prepared  artificially,  are  found  to  be  fully  as  effeflual 
as  those  obtained  from  the  mineral  spring  itself.  Citizen  Paul 
and  Company  have  instituted  an  establishment  for  this  purpose; 
and  already  the  waters  of  Bareges  and  Loueche,  &c.  are  pre- 
pared artificially,  and  used  at  this  place  in  the  form  of  baths  or 
pumpings  w^ith  much  success.  For  this  we  have  the  testimony 
of  Dr.  Lafisse,  inspeiSlor  of  the  establishment. 


CHAPTER  XXII. 


OF  THE  DEVIATIONS  OF  BONES, 

AND    THE    MEANS   USED    FOR    PREVENTING   AND    CORRECTING 
THE    DEFORMITY    ARISING    FROM    THEM. 

THE  bones,  which  give  proportions  to  our  different  parts, 
and  by  which  we  are  maintained  in  the  eredl  posture, 
may  grow  in  an  unnatural  direftion  •,  and  like  the  branches  of  a 
tree,  whose  growth  is  impeded  by  any  cause,  may  bend  under 
the  weight  of  the  body  and  the  a6lion  of  the  muscles,  so  as  to 
render  motion  extremely  inconvenient.  But  it  is  only  in  in- 
fancy, when  the  tissue  of  the  bones  is  flexible,  and  the  ossifi- 
cation incomplete,  that  this  vitiated  conformation  can  take 
place.  Affections  of  this  kind  are  very  easily  prevented,  but 
are  very  difficult  to  remove,  and  are  entirely  incurable  unless 
encountered  before  they  have  attained  a  certain  degree. 


OF    THE    DEVIATIONS    OF    BONES,    &C.  315 

They  are  sometimes  occasioned  by  negle^  in  the  clothing 
nnd  exercise  of  children  ;  in  other  cases,  they  arise  from  a  want 
of  equilibrium  in  the  aftion  of  certain  antagonist  muscles.  Thus 
confining  children  in  swaddling-clothes,  the  use  of  stays,  pre- 
hiature  exercise,  and  the  habit  of  remaining  in  bad  attitudes, 
as  frequently  occasion  them  as  the  difference  arising  primarily 
in  the  aftion  and  disposition  of  the  muscles. 

Physicians  had,  for  a  long  time,  raised  their  voice  against 
the  barbarous  use  of  swaddling-clothes,  in  which  the  limbs  of 
the  infant  were  so  clogged,  and  kept  in  such  a  state  of  inac- 
tivity, that  they  could  neither  grow  nor  acquire  strength ;  but 
it  remained  for  the  persuasive  eloquence  of  Jean -Jacques  to  ef- 
fedl  a  revolution  in  this  part  of  physical  education,  which  rea- 
soning could  not  produce.* 

Children  are,  now-a-days,  scarcely  ever  wrapped  up  in  swad- 
dling-clothes :  they  are  generally  covered  with  wide  and  warm 
vestments,  which  protect  them  from  the  cold,  and  at  the  same 
time  do  not  prevent  the  developement  of  their  organs. 

The  use  of  stays  is  no  less  obje<Stionable.  The  breast  and 
superior  part  of  the  abdomen  is  surrounded  with  these  cuirassesy 
with  the  view  of  diminishing  their  capacity,  and  giving  to  the 
waist  a  delicacy  altogether  unnatural,  and  consequently  remote 
from  beauty.  But  they  are  not  only  injurious  to  beauty  alone, 
their  effects  are  pernicious  to  health  -,  wide  above,  and  growing 
narrow  downwards,  they  resemble  a  cone  placed  inversely  to 
that  formed  by  the  thorax,  which  is  naturally  wider  at  its  in- 
ferior part  than  at  its  summit.  The  breast,  subjected  to  con- 
tinual compression,  must  become  deformed,  and  have  its  form 

*  '•  All  our  wisdom  consists  in  servile  prejudices  ;  all  our  customs  are 
**  subjugating,  painful,  and  re  tri6live.  Civilised  man  draw-  hi-;  first 
••  breath,  and  expires — in  slavery  ;  at  birth,  he  is  laid  in  swaddling-clothes, 
**  when  dead,  he  is  nailed  down  in  a  coffin.  At*  long  as  he  preserves  the 
*•  human  figure,  he  is  enchained  hy  our   institutions 

"  The  new-born  child  has  need  of  ptietching  himself  and  moving  his 
"  limbs,  to  shake  off  that  torpor,  in  which,  rulled  up  like  a  ball,  he  has 
*'  remained  for  so  long  a  time.  His  limbs  are  extended,  it  is  true,  but 
**  confined  in  such  a  manner  that  iie  cannot  move  them  ;  his  head  is  tied 
«*  down  by  stay  bands  ;  it  would  seem  to  be  feared  that  he  should  have 
"  the  appearance  of  being  alive. 

*•  Thvs  the  impulsion  from  within,  or  the  tendency  of  the  internal 
"  parts  to  grow  and  be  developed,  meets  an  insurmountable  opposition, 
*'  The  infant  makes  continual,  but  useless  efforts,  which  exhaust  his 
"  force,  and  retard  the  accession  of  strength.  He  was  more  at  his  case, 
"  less  cramped,  and  less  compressed  in  the  amnios,  than  in  his  new  si- 
**  tuation }  I  do  not  see  what  he  has  gained  by  coming  into  the  world." 


3l6  OF    THE    DEVIATIONS    OF    BONES,    &C. 

changed  from  conical  to  oval,  or  both  its  extremities  made  nar- 
rower than  natural ;  hence,  in  consequence  of  the  lateral  de- 
pression of  the  ribs,  the  adtion  of  the  lungs  is  impeded,  diffi- 
culty of  respiration  brought  on,  and  a  remarkable  disposition 
to  phthisis  pulmonalis  induced.  However,  though  the  habitual 
wearing  of  stays  may  be  attended  with  these  disadvantages, 
still  they  are  not  to  be  altogether  proscribed,  as  there  are  cer- 
tain cases  in  which  they  may  be  used  with  some  advantage. 

Let  us  suppose,  for  instance,  the  shoulders  of  a  child  to  be 
of  a  different  height,  which  inequality  may  be  the  result  of  a 
bad  habit,  or  may  be  occasioned  by  the  muscles  on  each  side 
not  possessing  the  same  degree  of  force.  If  the  right  shoulder 
be  lower  than  the  left,  the  child  should  wear  stays  in  which  the 
notches  under  the  arms  are  not  on  a  level ;  that  in  the  right 
side  should  not  be  so  deep  as  that  in  the  left,  in  order  to  raise 
up  the  right  shoulder.  By  the  continued  use  of  this  apparatus, 
the  muscles  of  the  left  side  recover  strength  enough  to  balance 
those  of  the  right,  the  habit  of  remaining  in  a  bad  attitude  is 
interrupted,  and  the  child  is  restored  to  his  natural  shape.  It 
would  be  in  vain  to  recommend  the  child  to  incline  to  the  op- 
posite side,  as  a  force  which  he  could  not  subdue,  causes,  un- 
known to  him,  the  deformity.  It  is  necessary,  that  the  pressure 
made  by  the  corset  against  the  arm-pit  keep  him  constantly  in 
mind  of  making  resistance  to  the  depression  of  the  shoulder,  by 
throwing  into  action  the  muscles  of  the  opposite  side. 

The  vertebral  column,  naturally  curved  by  the  weight  of 
the  body,  is  liable  to  many  deviations.  We  have  treated  of 
those  arising  from  rickets :  we  will  mention  here  those  only 
that  arise  from  another  cause.  Children,  from  their  sight  be- 
ing naturally  very  weak,  or  from  contra<Sling  a  habit  of  stooping 
their  head  to  inspect  substances  closely,  bend  the  neck  beyond 
its  natural  limits ;  if  this  habit  be  neglefted,  and  nothing  done 
to  correct  it,  the  bones  become  indurated  in  this  curved  situ- 
ation, and  the  head  remains  always  inclined  forwards.  The 
same  thing  happens  in  the  back  or  loins  of  young  persons  of  a 
delicate  constitution.  The  extensor  muscles  of  the  trunk,  too 
weak  to  support  the  spine,  allow  it  to  be  preternaturally  bent 
by  the  weight  of  the  head,  thoracic  and  abdominal  viscera. 
The  nature  of  the  person's  occupation  influences  very  much 
the  diredlion  in  which  the  curvature  takes  place.  The  breast 
and  shoulders  are  consequr^ntly  deformed  ;  the  former  becomes 
prominent  on  the  side  towards  which  the  curvature  tends,  and 
is  depressed  on  the  opposite  side.     The  use  of  stays  stuffed  at 


OF    THE   DEVIATIONS    OF    BONES,   &C.  317 

the  side,  opposed  to  the  curvature  or  prominence  of  the  spine, 
is  then  to  be  recommended ;  or  the  machine  of  Levacher,  de- 
scribed in  the  fourth  volume  of  the  Memoirs  of  the  Academy 
of  Surgery,  may  be  used.  A  vertical  piece  of  iron  ascending 
along  the  spine,  and  embracing  the  back  part  of  the  head  by 
two  wings  reaching  to  the  forehead,  and  a  circular  bandage  to 
keep  the  head  extended,  are  the  principal  parts  of  this  inge- 
nious machine,  repeatedly  applied  with  success  by  the  inventor 
of  it.  If  the  head  only  is  bent  forwards,  a  pasteboard  stock 
very  high  anteriorly  may  be  worn.  Whatever  mechanical 
means  are  used,  they  should  be  applied  in  such  a  manner  as 
not  to  impede  in  the  smallest  degree  the  motion  of  the  affefted 
parts.  In  faft,  it  is  an  essential  point  to  combine  exercise  with 
them,  which  it  is  known  is  the  best  means  of  re-establishing 
the  strength  of  the  enfeebled  muscles.  Tonics,  cold  bathing, 
friftion,  a  nourishing  diet,  and,  in  short,  every  thing  recom- 
mended in  the  treatment  of  rickets,  are  to  be  combined  with 
the  use  of  machines. 

If  the  child  be  very  young,  and  cannot  walk  without  the 
assistance  of  leading-strings,  the  precaution  must  be  taken  of 
sewing  these  to  a  broad  girdle,  so  attached  to  the  child's  clothes 
that  it  may  support  the  entire  body  without  ascending  up  under 
the  arm-pits,  and  thus  compressing  the  axillary  nerves  and 
vessels.  In  general,  the  use  of  girdles  and  leading-strings  is 
injurious;  children  should  be  left  to  themselves,  and  not  forced 
to  walk  before  their  strength  admits  of  it.  Premature  walk- 
ing, by  making  the  legs  bend  under  the  weight  of  the  body, 
render  them  sometimes  bowed ;  at  ether  times  the  knees  are 
turned  inwards,  that  is  to  say,  the  child  is  in-kneed,  and  the 
feet  are  turned  outwards  *,  for  the  position  of  the  feet  is  always 
influenced  by  that  of  the  knees ;  thus,  when  the  knees  are 
turned  inwards,  the  feet  are  turned  outwards,  and  vice  versa. 

It  is  important  to  know  this  relation  necessarily  resulting 
from  the  disposition  of  these  parts,  when  we  attempt  remedy- 
ing their  mal-conformation.  It  is  on  the  knowledge  of  it  that 
is  founded  the  simple  but  efficacious  pradlice  of  raising  the  in- 
ternal edge  of  the  foot,  when  the  knee  inclines  too  much  in- 
wards ;  and  of  raising,  on  the  contrary,  the  external  edqe, 
when  the  knee  is  turned  outwards,  and  the  leg  bowed.  ' 

When  a  child,  from  having  been  put  to  \valk  too  soon,  or 
from  any  other  cause,  shall  be  in-kneed  or  bow-legged,  nothing 
is  to  be  done  in  the  first  case  but  to  have  the  internal  edj^e  of 
the  sole  of  the  shoe  made  somewhat  thicker ;  and  in  the  se- 


31 8  OF    THE    DEVIATIONS   OF    BONES,    &C, 

cond,  to  have  the  same  done  to  the  external  side.  The  con- 
stant addudlion  and  abdu6lion  of  the  foot,  if  this  simple  pre- 
taution  be  attended  to,  influences  in  time  the  knee,  and  insen- 
sibly makes  it  straight.  This  treatment  will  be  certainly  suc- 
cessful if  the  child  be  young  :  his  bones,  flexible  at  this  time> 
will  yield  easily  to  the  force  used  to  straighten  them. 

There  is  another  species  of  malconformation,  in  which  the 
feet  are  turned  entirely  either  inwards  or  outwards.  Persons 
labouring  under  this  distortion,  to  whatever  side  the  sole  of  the 
foot  is  turned,  are  said  to  be  club-footed.  The  Romans  dis- 
tinguished two  species  of  this  deformity :  they  call  those  vari 
whose  feet  were  turned  inwards,  and  va/gi  those  whose  feet  were 
turned  outwards. 

In  the  first  species,  the  sole  of  the  foot  is  turned  inwards^ 
its  internal  edge  becomes  the  superior,  and  its  external  the  in- 
ferior :  the  toes  are  bent ;  and  the  back  of  the  foot,  turned 
outwards,  is  usually  more  arched  than  natural.  The  contrary 
circumstances  are  observed  in  the  second  species.  In  bothj 
the  deviation  of  the  foot,  when  carried  to  a  certain  degree^ 
renders  progression  extremely  difficult. 

This  deformity  is  occasioned  by  an  inequality  in  the  respec- 
tive force  of  the  adductors  and  abdudlors  of  the  foot ;  which 
inequality  may  depend  on  the  position  in  which  the  foetus  was 
placed  in  the  womb,  or  on  the  manner  in  which  it  has  been 
treated  after  birth. 

Nothing  is  easier  than  to  discover  the  affeftion,  even  though 
very  inconsiderable ;  the  leg  itself  is  deformed  and  curved  out- 
wards if  the  sole  of  the  foot  is  turned  inwards,  and  vice  versa. 
It  is  of  the  greatest  importance  to  oppose  the  deviation  of  the 
foot  at  the  moment  that  it  begins  to  take  place.  The  bones  are 
then  soft,  cartilaginous,  and  flexible,  and  take  any  form  giveti 
to  them  -,  but  as  the  person  advances  in  age,  they  become  hard) 
preserve  the  false  position  in  which  they  have  been  drawn,  and 
the  part  remains  forever  deformed. 

As  the  foot  is  oftener  turned  inwards  than  outwards,  the 
most  useful  apparatus  in  the  greatest  number  of  these  casesj 
consists  of  a  boot  or  buskin,  to  the  sole  of  which  is  attached  a 
spring  bent  into  a  semicircle.  This  boot  is  to  be  worn  by  the 
patient  in  such  a  manner  as  that  the  convexity  of  the  same  cir-* 
cle  may  bear  against  the  external  part  of  the  leg.  The  spring 
thus  curved,  attached  below  to  the  sole  of  the  foot,  and  above 
to  the  external  and  superior  part  of  the  leg  by  means  of  a  broad 
knee-band,  tends  constantly  to  become  straight,  presses  on  the 


OF    THE    DEVIATIONS    OF    BONES,    &C.  3I9 

external  side  of  the  leg,  and  at  the  same  time  serves  to  bring, 
the  foot  outwards.  If  its  use  be  persisted  in  from  a  very  early 
period  until  the  process  of  ossification  is  finished,  the  limb  may 
be  brought  to  its  natural  direction.  But  it  is  impossible  to  ef- 
fe6l  this  when  the  treatment  has  not  been  commenced  early, 
and  before  the  parts  have  acquired  their  entire  consistence.  In 
such  cases,  the  patients  should  wear  the  boot  and  spring  during 
his  life. 

The  internal  use  of  tonics  should  be  combined  with  the  ap- 
plication of  this  apparatus,  for  frequently  these  distortions  are 
accompanied  with  symptoms  which  indicate  a  state  of  cachexy 
or  general  debility. 

When,  in  consequence  of  a  burn,  a  limb  remains  contracted, 
the  cicatrices  must  be  destroyed,  and  the  limb  brought  to  its 
proper  direftion,  and  kept  so  by  means  of  a  proper  apparatus 
until  the  wound  is  healed.  If,  after  an  extensive  burn  of  the 
palm  of  the  hand,  the  fingers  are  contradted  and  kept  con- 
stantly bent,  an  incision  must  be  made  into  the  cicatrix,  but 
not  deeper  than  the  skin,  lest  the  vessels,  nerves,  and  tendons, 
so  numerous  in  this  part,  might  be  wounded,  and  the  fingers, 
after  being  extended,  must  be  attached  to  a  broad  piece  of 
board  placed  on  the  back  of  the  hand.  By  this  means  the 
wound  will  heal,  while  the  fingers  are  kept  parallel  to  the  bones 
of  the  metacarpus. 

A  little  girl  was  admitted  into  the  hospital  de  la  Charite, 
with  her  fingers  reverted  on  the  back  of  her  hand  in  conse- 
quence of  a  burn  :  the  froena,  which  confined  them,  were  di- 
vided transversely  behind  the  articulation  of  the  first  phalanges, 
with  the  bones  of  the  metacarpus  :  the  fingers  were  brought  to 
their  natural  direction,  and  fixed  so  by  means  of  a  board  pla- 
ced on  the  palm  of  the  hand,  and  some  lint  was  put  between 
the  lips  of  the  wound.  Each  finger  was  tied  by  a  little  band 
which  passed  through  the  clefts  of  the  board,  so  that  the  wounds 
on  the  back  of  the  hand  might  be  dressed  without  deranging 
the  apparatus.  A  larger  cicatrix  was  formed,  and  the  girl  re- 
covered without  any  deformity. 

When  cicatrices,  in  consequence  of  a  burn,  gangrenous  carbun- 
cle, or  any  other  loss  of  substance,  take  place  at  tlie  anterior- 
part  of  the  neck,  the  skin  is  often  overstretched,  and  fisena  are 
formed,  which  keep  the  head  bent  and  turned  more  or  less  lO 
one  side.  In  such  cases,  as  in  every  other,  the  frsena  must  be 
cut,  the  lips  of  the  wound  separated  and  dressed  with  lint, 
and  the  head  kept  extended  during  the  formaticn  of  the  new 


320  OF    THE    DEVIATIONS    OF    BONES,    &C. 

cicatrix.  The  iron  cross  of  Heister,  and  in  general  all  the  ma- 
chines proposed  for  remedying  curvatures  of  the  spine,  may 
be  employed  for  preserving  the  head  in  its  proper  direction. 

In  contractions  arising  from  the  continual  contracted  state  of 
the  flexor  muscles,  it  is  often  useful  to  contend  against  the 
force  of  these  muscles,  and  bring  the  limb  straight.  This  di- 
rection is  the  most  favourable  for  the  functions  of  the  limbs, 
even  when  they  are  anchylozed. 

A  young  man,  in  consequence  of  an  abscess  which  formed  in 
the  posterior  and  inferior  part  of  the  thigh,  and  which  was  fol- 
lowed by  a  great  loss  of  the  cellular  substance  of  the  ham,  and 
of  that  about  the  popliteal  vessels  and  nerves,  had  the  biceps 
cruris,  semitendinosus  and  semimembranosus  muscles,  so  con- 
tracted, that  the  leg  formed  a  right  angle  with  the  thigh.  The 
leg  could  be  extended  by  a  force  that  overcame  the  contraction, 
but  quickly  reassumed  the  bent  state  on  the  removal  of  the 
force.  Professor  Boyer,  convinced  that  in  this  case  it  was  ne- 
cessary  to  contend  unceasingly  against  a  power  that  was  always 
aCting,  had  a  machine  constructed  by  Citizen  Oudet,*  which, 
by  keeping  the  limb  in  a  constant  state  of  extension,  both  du- 
ring rest  and  exercise,  at  length  overcame  the  contraction. 

*  This  ingenious  artist,  honoured  by  the  approbation  of  the  Academy 
of  Surgery,  and  esteemed  worthy  of  national  rewards,  live  in  the  street 
des  Fosses  Saint-Germain-des-Pres,  Hotel  de  la  Fautriere,  Paris.  The 
different  apparatus  for  fra6lures  of  the  clavicle,  neck  of  the  femur,  and 
patella,  an  engraving  and  description  of  which  are  given  in  this  work, 
hive  been  construfted  by  him. 


ANALYTICAL  INDEX. 


ABSCESSES  ;  the  dimension  of  the  opening  made  in  them  to  be 
regulated  according  to  th'.ir  situation  and  cause,  page  283. 
'Al'veolar  process,  partly  (with  one  or  more  teeth)  detached  in  a  frac* 

ture  of  the  superior  maxillary  bones ;  treatment,  45. 
Anchylosis  :  distinguished  into  complete  and  incomplete,  3 Id. 
seldom  a  primary  diseasej  ibid. 
anchylosis  from  inadion  arises  from  the  dimindtidn  or  cessation  of 

the  secretion  of  the  synovia,  311. 
a  case  of  complete  anchylosis  ot  all  the  joints  might  happen  froth 

long  confinement  motionless  in  bed,  ibid. 
influence  of  the  causes  which  produce  this  disease ;  as,  from  a  bone 

fradlured  in  the  neighbourhood  of  a  joint,  ibid. 
thestifFness  succeeding  to  fradures  has  been  erroneously  attributed 
to  an  effusion  of  osseous  matter  (36  and  37)  into  the  interior  of 
the  joint,  312. 
mode  in  Which  anchylosis  takes  place,  always  thfc  same,  it. 
the  distindion  of  complete  and  incomplete  essential  to  be  observed 
irt  regulating  the  treatment ;  when  the  former  will  ensue,  such  a 
previous  disposition  should  be  made  of  the  parts  as  will  be  most 
convenient  after  its  determination,  ibid. 
•^measures  for  prevention  or  removal  of  the  latter,  45,  313  and 
314. 
Aneurism  :  the  laceration  of  a  vein  may  be  easily  mistaken  for  H  false 

primitive  aneurism,  34. 
Apparatus  by  which  a  patient  may  raise  himself  in  bed,  67. 
Articulations.    See  the  articles  Dropsy;  Foreign  Bodies; 

White  Swellings;  and  Wounds. 
Astragulus,  may  in  some  cases  of  lu:(ation  of  the  foot,  be  extirpated 
with  advantage  ;  instances,  286. 
fraSures  o\  this  bone  :  See  the  article  Tarsus. 
its  luxations :  See  the  article  Foot. 

Bandages :  their  importan<»,  in  cases  of  fraftare,  to  maintaining  the 
fragments  iii  the  relative  position,  2^. 
their  inefHcacy,  however,  to  preserve  the  fraftured  portions  in  just 

contadt,  26. 
— examination  of  the  different  sorts  of  bandages,  in  this  latter 

view  ;   1 ,  the  roller,  ib. 
• — 2,  the  eighteen-tailed  bandage ;  its  construdion,  and  applica- 
tion :  preferable  to  the  former,  ib. 
—3,  Scultet's  bandage ;  its  construdion,  and  application,  27. 

this,  in  most  cases,  superior  to  the  other  two,  ib. 
the  great  use  of  bandages,  ib. 
Bladder",  treatment  of,  when  perforated  by  a  splinter  from  a  fraflure 

of  the  pelvis,  6j. 
Bones  :  cause  of  their  hardness ;  and  operation  of  this  cause  in  the 
several  wounds  and  disorders  of  the  bones,  9  and  10. 
41 


322  ANALYTICAL    INDEX. 

(Bones.     Continued.) 

division  of  the  diseases  of  the  bones  into  two  classes,  lo. 
Buttocks :  dangerous  consequences  of  concealing  violent  falls  on  this 
part ;  instance,  65. 

Cakis  as:  causes  by  which  it  may  he/ra^ureJ;  muscular  aftion,  or 
external  violence,   152. 

— instance  of  the  former  case,  i^. 

signs  of  this  fra£lure,   153. 

method  of  setting,  ii. 

— of  keeping  the  foot  and  leg  in  the  proper  position,  iiiif. 

time  of  consolidation,  ih. 

luxations  of  this  bone  :  See  the  article  Foot. 
Callus:  formation  of;  different  opinions  of  the  mode  in  which  the 
consolidation  of  the  fraftured  portions  of  bones  is  efFefted,  36. 

— opinion  of  the  ancients ;  ascribing  it  to  the  effusion  of  the  osseous 
juice,  36  and  37. 

—a  modern  opinion  ;  attributing  it  to  the  periosteum,  37. 

—a  true  principle  on  this  subject;  analogy  between  what  takes 
place  in  the  cases  of  a  solution  of  continuity  in  the  soft  and  in  the 
osseous  parts,  38. 

progress  of  the  generation  of  callus,  39. 

— it  is  formed  with  more  promptitude  and  facility  in  youth  than 
in  more  advanced  age,  ii. 

—its  formation  how  affeded  by  extreme  old  age,  or  by  difference 
of  sex,  ii. 

——by  the  state  of  pregnancy,  40. 

local  circumstances  by  which  its  produdion  may  be  retarded ;  by 
the  want  of  a  due  quantity  of  blood  to  one  of  the  fraftured  por- 
tions, ib. 

—by  the  surfaces  of  the  fragments  being  not  preserved  in  just  con- 
taft  and  in  pcrfeft  immobility,  Of, 

usual  period  in  which  consolidation  is  effefted ;  vulgar  prejudice 
on  this  subjeft,  41. 

—examine  the  state  of  the  limb  at  the  expiration  of  that  period  : 
treatment  to  be  adopted  in  different  circumstances  of  its  appear- 
ance then;  i.  If  it  is  swelled,  or  exhibits  a  tumour  and  is 
shortened  and  moveable,  41. 

2,  if  the  pieces  are  moveable  and  separated,  but  no  contraction, 

a. 

— 3,  if  the  fraflure  has  not  consolidated,  but  with  a  shortening  and 
deformity  of  the  limb : — when  the  ends  pass  each  other,  or  the 
surfaces  are  partially  in  contaft  or  totally  separated,  i5. 

when  the  portions  continue  very  moveable  on  one  another, 
thoHgh  the  just  position  has  been  preserved,  42. 

—In  casis  of  nut  proper  consolidation,  after  a  term  of  several 
months,  iB. 

—When,  after  using  all  other  means,  the  pieces  do  not  unite,  last 
resource,  of  cutting  off  their  extremities  (see  the  article  Extre- 
mities), 42  to  44. 

the  patient  is  not  to  be  at  once  allowed  the  free  use  of  the  limb  after 
the  reunion  of  the  fradure,  44. 


ANALYTICAL    INDEX.  J23 

{Callus.     Continued.) 
methods  of  removing  a  false  anchylosis  occasioned  by  the  motion- 
less state  of  the  member  during  cure,  ib. 
The  formation  of  callus  greatly  retarded  by  the  scurvy,  22. 
— it  has  even  been  observed  to  be  destroyed  by  that  cause,  after 
it  had  been  formed,   198. 
Caries.     The  nature  of  this  disease  much  involved  in  obscurity, 
164. 
somewhat  analogous  to  certain  ulcers  of  the  soft  parts,  ib. 
spongy  bones,  and  those  of  young  persons,  most  liable  to  it,  ib. 
has  been  confounded  with  necrosis,  and  with  exostosis ;  its  p^cu> 
liar  symptoms,   and  difference  in  this  respeft  from  necrosis, 
157,  165. 
its  causes :  distinguished  into  internal  and  external ;  the  former 

most  frequent,   165. 
abscesses  said  to  occasion  sometimes  caries;  they  are,  however, 

in  the  cases  alleged,  its  consequence  and  not  its  cause,  ib. 
is  seldom  produced  by  an  external  cause,  and  may  almost  always 

be  ascribed  to  a  disease  of  the  system,   166. 
— the  operation  of  scurvy,  as  a  cause  of  caries,  ib. 
——of  scrofula ;  bones  which  it  most  frequently  alFeds  in  this 
manner,  ib. 

3f  the  venereal  disease,  iB. 
of  cancers  of  the  mamma:,  ib. 
diagnosis,  in  different  cases  :  as,  in  superficial,  deep-seated,  or  in- 
accessible bones ;  in  constitutional  diseases ;  and  in   syphilii, 
— in  caries  of  the  vertebra?,  ib. 
prognosis  ;  most  favourable  in  spongy  bones,  and  in  those  of   the 

\6-j. 
carpus  and  tarsus,  ib. 

—•in  affeftions  of  these  latter,  and  in  short  bones  in  general,  and 
in  the  extremities  of  long  ones,  amputation  is  frequently  the  only 
resource,  ib. 
caries  from  an  external  cause,  less   dangerous  also  than  from  an 
internal ;  and  of  the  latter,  that  from  scrofula  or  cancer  more 
dangerous  than  from  lues  and  scurvy  ;  more  dangerous  likewise 
to  old  than  to  young  persons,  16S, 
Treatment,  very  irregular  :  praftice  of  the  ancients,  and  of  some 
moderns  ;  must  be  determined  by  a  close  view  of  the  evil  against 
which  it  is  to  be  direfted,  ib. 
—if  produced  by  an  affeftion  of  the  system,  this  to  be  ascertained 

and  combated  with  appropriate  remedies,  ib. 
— if  by  an  external  cause,  or  remaining  after  the  removal  of  the  in- 
ternal one,  apply  stimulating,  or  absorbent  and  neutralizing,  sub- 
stances, 169. 

but  if  these  are  ineffeflual,  use  more  aflive  one?,  which  will 
reduce  the  part  to  the  state  of  a  simple  necrosis,   169. 

should  the  caries  be  very  humid,  the  actual  cautery  must  be 
resorted  to,   (except  in  certain  cases)  ;  rules  fcr  its  application  ; 
its  manner  of  attion,   169  and  170, 
Modifications  of  this  general  treattnent,  in  particular  bones  ;   in  the 
bones  of  the  cranium,  171. 


324  ANALYTICAL    INDEX. 

(Caries.     Continaed.) 

—{In  the  mastoid  portion  of  the  temporal  bone  the  cautery  is  p^jr- 
ticularly  applicable,  ib. 

—In  the  bones  of  the  face,  nose,  and  palate,  ib. 

—-In  those  of  the  antra  maxillaria,   171. 

—In  the  OS  unguis;  and  scorbutic  caries  of  the  alveolar  procesf;, 
ib. 

—In  caries  of  the  spine:  its  dangerous  prognosis,  171   and  172, 
Its  symptoms,   J73. 
insufficiency  of  art  in  the  treatment  of  this  afFe^ion,  ib. 

—In  carjej  of  the  sternum  :  rapid  progress  of  the  afFe6lion  in  this 
"'bone,  and  its  dangerous  conseq^iiences,  174,. 

-I— remarkable  instance  of  a  spontaneous  recovery,  ib. 

—— treatment ;  in  the  application  of  caustics,  or  of  cutting  instra- 
ments,  ib. 

—In  caries  of  the  ribs,  or  of  the  bones  of  the  pelvis,  175. 

—In  caries  of  the  different  parts  of  the  iliac  bone,  ib. 

In  caries  of  the  extremities  of  long  bone,  ib. 

Its  affinity  with exotosis,  which  frequently  terminates  in  caries,  177. 
Carpus  i  nature  and  treatment  of  yra^ar^5  of,  93. 

luxations  oi  its  bones  vyiih  those  of  its  fore-arm,  259. 

these  luxations  may  take  place  forwards,  backwards,  inwards,  or 
outwards  5  the  first  two  sorts  the  rao5t  frequent,  260. 

peculiarity  of  the  articulation  of  the  hand  with  the  fore-arip,  in 
admitting  of  flexion  and  extension  near/y  to  the  same  extent,  ib. 

cause,  and  process,  of  luxation  backwards ;  its  signs  and  method 
of  reduftion,  ib. 

luxation  forwards  ;  Its  cause  ;  it  Is  rarely  complete  ;  is  difficultly 
distinguished  from  a  sprain,  all  doubtful  cases  to  be  treated  as 
luxations,  ib. 

luxation  either  backwards,  or  (particularly)  forwards,  accompa- 
nied wiih  laceration  of  the  ligaments,  and  followed  by  trouble- 
some inflammatory  swelling  ;  treatment  after  redu£lion,  ib. 

luxation  inwards,  or  outyyards :  never  complete ;  its  diagnosis ; 
method  of  reduction  ;  the  danger  depends  chiefly  on  the  strain- 
ing and  laceration  of  the  soft  parts,  261. 

Luxations  of  the  bones  of  the  Carpus  and  Metacarpus,  ib. 

luxation  of  the  heaci  pf  the  os  magnum  backwards ;  inflance,  and 
treatment,  z6i  and  26Z. 
C^r«J^J  of  FRACTURES  ;  divided  into  predisposing,  and  remote,  18. 

the  predisposing  causes ;  the  situation  of  the  functions  of  the  bones ; 
instances,  ib. 

— ^he  age,  and  the  diseases,  of  individuals ;  instances,  ib. 

—a  certaii  degree  of  cold  improperly  reckoned  among  these  cau- 
ses, 19. 

the  rem  le  causes,  and  their  different  operation,  ib. 

—I,  when  the  frafture  is  produced  at  a  distance  from  the  parts  on 
which  the  force  is  applied  ;  instances,  ib. 

—2,  when  produced  exaftly  on  the  part  struck;  instance,  ib. 
case  of  comminutive  fradure,  ib. 

Causes  of  Luxation;  are  divided  into  external  and  internal  j 
and  both  are  predisposing  or  occasional,  207. 


ANALYTICAL    INDEX.  J25 

(Causes  o/ivx  AT  ION.     Continued.) 

1,  the  predisposing:  are  either  nataral  or  accidental :  the  natu- 
ral ;  as,  confirmation  of  the  joint,  ligaments,  articulations. 
&c.  il>. 

—the  accidental ;  zs,  disease,  in  various  cases,  2g8. 

2,  the  occasional  causes  ;  the  efFeftof  these  depends  upon  the  dl- 
reftion  of  the  axis  of  the  bone  at  the  moment,  209. 

—in  the  round  articulations,  the  adtion  of  the  muscle  has  always  a 

share  in  producing  the  luxation,  208. 
— in  some  cases,  muscular  adlion  alone  will  efFeft  a  luxation,  209. 
luxations,  from  whatever  causes,  always  accompanied  with  lacera- 
tion of  the  ligaments  surrounding  the  joint,  209. 
Children  :  caution  against  a  dangerous  manner  of  playing  with  (hem  ; 
in  an  instance  of  a  iatal  luxation  of  the  vertebrs  thus  occasi- 
oned, 227. 
See  also  the  article  Deviations  of  the  Bones, 
Clavicle:  On  the  Fracture  of  this  bone;  it  is  very  liable  to  this 
accident,  from  various  circumftances,  72. 
the  fradture  may  be  at  any  part  of  the  length  of  the  bone;  and  ei- 
ther transverse  or  oblique,  simpleor  differently  complicated,  :i. 
— -frafture  caused  by  contre-coup,  is  not  necessarily  complicated 

with  contusion,  ih. 
derangements  of  the  broken  portions,  73. 

—mechanism  of  these  derangements ,  the  external  portion  is  al- 
ways that  which  is  deranged,  ii. 
falling  of  the  arm  in  a  fradlure,  ii. 
signs  of  frafture,  :i. 

by  what  complications  these  fradlures  are  rendered  dangerous,  74. 
examination  of  the  various  bandages  invented  for  this  frafture  ;  that 

of  the  ancients,  ii. 
— that  in  the  form  of  the  figure  8.  ii. 
——different  modifications  of  this  latter,  li. 
the  proper  treatment,  75. 

— account  of  Desault's  appropriate  apparatus,  75  and  76, 
— improved  invention  of  Boyer,  77. 

treatment  of  a  simple  fradlure  by  means  of  this  latter  con- 
trivance, ill. 
treatment  of  compound  fraftures,  ii. 
caution  in  using  Desault's  bandage,  /^. 

On  Luxations  of  this  bone  ;  these  are  much  less  frequent  than  frac- 

tures,  235. 
I,  of  Luxations  of  the  Extremity  near  the  Sternum,  iL 
these  dislocations  are  favoured  by  the  conformation  of  the  parts,  ii, 
may  take   place  forwards,    backwards,   or   upwards ;    but   never 

downwards,  235. 
— the  anterior  most  frequent ;  the  others  very  rare,  particularly 

the  backward,  236. 
manner  in  which  the  anterior  luxation  is  effefted  ;  instance,  ii. 
—the  upward,  ii. 

— the  backward,  the  treatment  of  this  is  difficult,  236. 
—Diagnosis  of  each,  238, 


J26  ANALYTICAL    INDEX. 

(Clavicle:  luxations  oi.     Continued.) 

the  redudlion  to  be  efFefted  in  the  same  manner  as  in  cases  of  frac- 
ture,  75,  238. 

—and  the  apparatus  also  the  same,  77  and  238. 

2,  of  Luxations  of  the  Extremity  next  the  humerus,  239. 

these  luxations  very  rare,  and  scarcely  occur  in  any  other  direflion 
than  upwards,  ib. 

— cause,  and  process,  of  dislocation  in  that  diredlion,  ib* 

•*—— manner  in  which  it  is  efFedted.  ib. 

—diagnosis,  240. 

— prognosis,  less  dangerous  than  affirmed  by  Pare,  ib. 

— the  luxation  often  imperfcdly  reduced,  ib. 

— method  of  redudlion  ;  bandage,  77  and  240. 

Instance  in  which  a  dislocation  of  this  bone  was  mistaken  for  ex- 
ostosis, 178. 
Coccygis  os;  ttidomfraiiured,  65. 

signs  of  such  an  accident,  ib. 

treatment,  ib. 

dangerous  consequences  of  concealing  violent  falls  on  the  buttocks, 
ib. 

— instance,  ib. 

IjCss  easily  luxated ;  instance,  however,  of  this  accident,  228. 
CoU  improperly  accounted  a  predisposing  cause  of  frafture,  18. 
Comminuti've  fra£iure  described,   12. 

treatment,  in  various  circumstances ;  and  cases  in  which  amputa- 
tion is  necessary,  34,  35,  and  36. 
Complete  and  incomplete fradures  ;  this  distinftionis  unfounded,  17. 
Compound fraBure  defined,    17. 

treatment  in  the  different  cases  of  complication  (See  the  article 
Treatment'),   32  to  36. 
Consolidation  offraclures.     See  the  article  Callus, 
Contrat5ions  occisioned  by  burns ;  treatment  for,  319. 

— by  the  continual  contraded  state  of  the  flexor  muscles ;  instance, 

320- 
Counter-extension,     See  the  article  Extension. 
Crepitation  the  most  general  and  distinftive  symptom  of  frafture,  z©. 

methods  of  discovering  the  existence  of  this  criterion,  20. 
Crutches  ;  vast  importance  of  a  proper  and  sufficient  use  of  them  in 

recovery  from  a  fradure  of  the  lower  extreniities,  44. 

Demi-Jlexion ;  comparative  advantages  and  disadvantages  of  this  po- 
sition, and  of  straightness,  for  a  fradlured  limb  during  cure,  35. 

Denudation  of  the  Bones.     See  the  article  Wounds. 

Derangement  of  the  fraftured  portions  of  a  bone  ;  its  causes  and  va- 
rieties, 13. 
these  latter  considered  :   1,  In  the  direftionof  the  diameter ;  and, 
2,  parallel  to  the  axis  :  instances  of  each,   14. 

3,  the  fragments  forming  an  angle  with  each  other  ;  instances,  ib, 

4,  derangement  afTedting  the  circumference  ;  instance,  ib. 
Causes  of  derangement ;  always  exterior:  as,   i,  the  cause  of  the 

fradure;  instances,  (case  of  the  celebrated  Ambrose  Pare),  15. 


ANALYTICAL    INDEX.  ^1'] 

z,  the  weight  of  the  limb,  or  the  impuUc  communicated  to  it 

during  the  dressing,   15. 
— 3,  the  most  powerful,  the  contraftion  of  the  muscles  (See  the 

article  Muscles),  ib. 
Complicated  derangements ;  instance,  ib. 
Deviations  of  the  bones,   and   the   deformity  arising   from 

them  ;  can  take  place  only  in  infancy,  314. 
their  causes ;  among  which  are  the  use  of  swaddling-clothes,  and 

of  stays,  315. 
—cases,  however,  in  which  stays  of  a  certain  construftion  may 

serve  to  correal  disproportions,  316,  317. 
caution  in  the  use  of  leading-strings ;  in  general  they  are  injurious, 

by  inducing  the  too  early  practice  of  walking,  and  thus  ocasion- 

ing  the  knees  to  become  turned  inwards  or  outwards,  317. 
— simple  and  efficacious  method  of  remedy  for  this  deformity,  318. 
deformity  of  the  feet,   {club-footed:  its  different  species:  cause; 

necessity  of  early  attention  to;  and  treatment,  ib, 
treatment  of  contraftions  occasioned  by  burns,  319. 
— by  the  continual  contracted  state  of  the  flexor  muscles;  instances, 

ib. 
Differences  oi  ■Lvx AT \Qii St  23. 

1,  witli  resped  to  the  articulation  in  which  they  take  place  ;  much 
more  frequent  in  the  round  or  loose  articulation  than  in  the  gin- 
glymoidal,  201;. 

2,  as  to  the  extent  of  the  dislocation  ;  distinflion  into  complete  and 
incomplete,  ib. 

— the  complete  instanced  in  luxation  of  the  humerus  or  femur,  204. 

— the  incomphte,  in  dislocation  of  the  head  of  the  astragalus,  ib. 

an  erroneous  distindlion  of  incomplete  has  been  attempted  to 

be  established,  206. 

— the  dislocation,  when  complete,  may  be  to  a  greater  or  less  dis- 
tance, ib, 

3,  as  to  the  direction  in  which  the  bone  is  displaced  ;  in  the  round 
articulations  it  may  be  in  the  direftions  of  all  the  radii  of  the 
circle,  ib. 

limitations  on  this  point,  from  circumstances  of  conforma- 
tion, ib. 
—— distindlion  of  inferior,  superior,  &c.  tb, 
— direftion,  in  the  ginglymoidal  articulations,  ib. 

4,  as  to  the  length  of  time  they  have  continued  ;  a  difference  of 
the  highest  importance,  207. 

— a  sufficient  interval,  may  even  have  rendered  the  reduftion  im- 
possible, ib. 

5,  as  to  the  accompanying  circumstances;  which  occasion  the 
distindlion  into  simple  and  compound,  ib. 

6,  as  to  the  cause  which  has  produced  them  :  See  the  article  Cau- 
ses of   LUXATION. 

Differences  of  fractures.     See  the  article  Species. 
Dropsy  of  the  articulations  (or  Hydarthrus)  ;  occurs 
only  in  the    knee,  288. 
rarely  co-exists  with  any  other  dropsical  affedlion,  but  is  produced 
by  local  causes;  their  operation,  289. 


328  ANALYTICAL    INDEX. 

(Dropsy  of  the  articulations.     Continued.) 
—may  be  occasioned  also  by  acute  or  chronic  fheumatisin,  and 

chronic  gout,  ib, 
coUeftions  of  synovia  sufficient  to  merit  this  name  erroneously  said 

to  have  occurred  in  the  hip-joint,  ib. 
this  disease  not  to  be  confounded  with  encysted  tumours  on  the  side 
of  THE   KNEE  near  the  patella;  (distinguished  symptoms  of 
these  latter  ;)  nor  with  certain  white  swellings  ;  (this  last  mis- 
take may  be  easily  made,)  290. 
distinguishing  symptoms  from  arthritic,  cedamatous,  and  white 

swellings  of  the  knee,  and  foreign  bodies  formed  in  it,  290. 
prognosis  unfavourable,  291. 

peculiar  mode  of  treatment  in  this  disease ;  by  topical  applica- 
tions, 291. 
—if  these  means  fail,  a  surgical  operation  to  be  resorted  to  ;  this 
described,  292. 
after  treatment,  ib. 
Dura  mater :  tumour  formed  by  fungous  excrescences  from  this  bone; 

may  be  mistaken  for  exostosis ;  diciinftive  signs,  178. 
Eighteentailed  bandage -y  its  construdion,  application,  and  compara- 
tive advantage,  26. 
Emphysema ;  its  produdion,  and  ^treatment  in  different  stages,  dz 

and  63. 
Exostosis  ;  distlnft  species  of,  176. 

different  cases  ;  the  ivory  exostosis,  the  Spungy,  and  that  compo- 
sed of  osseous  and  fleshy  parts,  ib. 
bones  which  are  mo*t  frequently  affefled  with  this  disease,  ib. 
its  different  appearances ;  almost  always  caused  by  lues  or  scro- 
fula ;  its  affinity  with  caries,  and  frequent  termination  in  that 
affet^ion,   176  and  177. 
very  rarely  proceeds  froni  an  external  cause,   r77. 
signs  of  a  scrofulus  diathesis,  ib. 
—of  a  venereal,  ib. 

diagnosis  ;  peculiarity  from"  that  of  a  pcriostosis,  ib: 
the  existence  of  exostosis,  sometimes  cannot  be  ascertained  before 

the  patient's  death  ;  instances,  ib. 
the  head  of  a  luxated  boncj  the  enlargement  of  the  ends  of  ricketty 
bones,  or  the  tumour  formed  by  fungous  excrescences  from  the 
dura  mater,  may  all  be  mistaken  for  exostosis,   178. 
general  effefts  of  exostosis  ;  a  sense  of  weight;  pain  ;  and  defor- 
mity, ib. 
' — particular  effedls :  as,  in   ejiostosis  in  the  orbit  of  theeye;  on 

the  pubis ;  or  on  any  of  the  bones  of  the  pelvis,  ib. 
Prognosis,  different  according  to  different  circumstances  ;  exos- 
toses from  an  external  cause  more  difficult  than  from  an  internal 
one ;  of  the  latter,  that  produced  by  a  scrofulus  diathesis  most 
so,  ib. 
Erroneous  opinions  in  the  general  pathology  of  this  affeftion,   179. 
Principles  of  treatment  ;  the  primary  disease  must  be  afcertained, 

and  made  the  chief  objeft  in  this  view,   179  and  180.. 
if  a  venereal  affedtion  has  existed,  oris  present,  in  the  constitution, 
mild  or  strong  applications  of  mercury,  Scq.   i8c. 


ANALYTICAL    INDEX.  329 

(Exostosis.     Continued.) 

— after  a  certain  time  and  efFeft,  the  general  remedies  to  be  dis- 
continued, ib. 

—caution  in  the  use  of  mercury  ;  little  reliance  in  these  cases  on 
topical  applications,  ib, 

treatment  in  scrofulous  cases  ;  often  inefFedlual,  ib.^ 

— if  the  exostosis  terminates  in  caries,  the  method  of  cure  the 
same  as  if  this  latter  had  been  the  original  afFeftion,   }8i. 

the  scorbiKic  and  the  cancerous,  exostoses,  ib. 

exostosis  from  an  external  cause,  or  merely  local,  should  (after  re- 
moving the  primary  disease)  be  left  to  nature  ;  the  use  of  caus- 
tics, or  the  aftual  cautery,  dangerous,  ib. 

—treatment  however,  when  the  tumour  presses  on  and  deranges 
some  important  organ  ;  removal  by  the  saw  ;  much  preferable 
to  the  chisel  and  mallet,  ib. 

direction  for  the  use  of  these  latter,  when  adopted,  ib, 
this  dreadful  remedy  seldom  justifiable,    i8z. 

Lamellated  exostosis,  ib. 
Extension  and  counter-extension  :  not  always  necessary  in  setting  a 
fractured  hone,  'i  instances,   23. 

the  hands  of  intelligent  assistants  always  best  for  both  these  pur- 
poses ;  more  powerful  means  injurious,  ib. 

should  be  applied  not  on  the  fragments  themseJve?,  but  on  the 
bones  which  articulate  with  them  ;  instances,  24. 

degree  of  force  to  be  employed  ;  and  its  direftion  ;  instances,  ih. 

Apparatus  for  effefting  perpetual  extension,  29. 

its  application  and  a£lion,  ib. 

— various  rules  on  the  former  point,  30  and  31. 

sundry  contrivances  for  eiFefting  perpetual  extension  and  counter- 
extension  in  fractures  of  the  neck  of  the  femur,   120  to  126. 

Some  remarks   respefting  the  method  of  making  extension  and 
counter-extension  in  a  case  of  Luxation,  245  and  246. 
See  also  in  the  article  Treatment  (general)  ot  luxations. 
Extremities  of  \.\ie  fractured  ^oxuor.s  of  the  bones  may  be  cut  off,  as 
a  last  resource  when  all  other  means  fail  of  making  them  unite, 

.42- 
this  pradlicable  only  in  the  femur  and  humerus,  ib. 

method  of  performing  the  operation,  ih, 

— unsuccessful  instance,  43  and  44. 

this  operation  very  difficult,  but  not  to  be  renounced  for  that  rea- 
son, 44. 

May  be  piaftised  also  on  iV,e  carious  extremities  incases  of  white 
swellings  of  the  joints,  307. 

— as,  of  the  knee  ;  method,  308. 

— of  the  humerus,  ib. 

instances,  ib, 

— instance,  of  the  knee,   309. 

——great  danger  of  this  case,  il. 

— method,  in  the  elbow,  310. 
Femur.     Luxations  oi  x.\\q  ii:mnr ;  not  frequent,  and  have  been  per- 
haps often  confounded  with  fradures  of  the  neck  of  this  bone^ 
264. 

42 


« 


■.*>A' 


330  ANALYTICAL    INDEX. 

(Femur,     Continued.) 
divided  into  four  species  :    i ,  luxation  upwards  and  outwards  ;  and 
2,  downwards  and  inwards;  these  two  the  most  frequent,   26/^. 
—3     luxation  upwards  and  forwards ;  and  4,  downwards  and  back- 

w.'.rdb  :  very  rare,   265. 
the  First  species  considered  :  its  process,  ih. 
— its   symptoms,  and   distinflive   diagnosis  from  frafturc   of  the 
neck  of  this  bone,  ih 

ause  of  the  limb  being  turned  inwards  in  this  loxation,  266. 

—  tn'Jch  laceration  and  irjury  done  to  tne  soft  parts,  ih. 
—method  of  effecting  re  ^uflion,  ih. 

signs  of  success  in  this  operation,  267. 

alter  treatment,  ih 

the  Second  species,  downwards  and  inwards;  its  causes,  and  pro- 
cess, 268. 

—  ubsequent  state  of  the  soft  parts  surroundjng  the  articulations, 
th 

— diagnosis  ;  too  striking  to  admit  of  any  mistake,  ih. 

—prognosis,  less  unfavourable  than  in  the  First  species  ;  method 
of   renufti  'n,   269. 

the  Third  species,  upwards  and  forwards  ;  very  rare  ;  instance, 
however,  ih. 

— --yroptnms,  ih. 

— prognosis  dangerous,  270. 

— reludlion,  same  as  in  the  preceding  species,  ih. 

the  Founh  species,  dow  .wards  and  backwards ;  may  be  either  pri- 
mary or  secondary,  ih. 

— general  symptoms  in  both  cases  and  peculiar  ones  in  each,  ih. 

—  he  secondary  class  muci  more  frequent  than  the  primary,  zyq* 
— ieJnftion,  same  as  in  the  preceding  species,  ih. 

GL.ieral  camion  in  the  reduction  of  these  luxations,  ih, 

cons -quences  of  luxations  of  the  First  and  Second  species,  if  not 
duced,  270  and  271. 

Spontaneous  Luxations  or  the  Femur.      SfC  that  article. 

Instance  of  the  carious  extremity  of  this  bone  and  of  the  tibia  cut 
cfF  in  the  ca«s  of  white  swelling,   309. 

For  i^rflf/arw  of  this  bone.  See  the  articles  Neck  of   the  Fe- 
mur; and  Th  igh. 
Fihula;  less  frequently  _/V<zr/Kr<?// than  the  tibia,   148. 

causes  by  which  it  is  exposed  to  this  accident ;  adion  exerted  on 
the  fibula  in  walking  on  uneven  ground,  ih. 

formation  and  disposition  of  this  bone  in  climbing  animals,   149. 

manner  in  which  it  is  fradtured  in  the  human  subjed^,  by  the  foot 
being  forcibly  turned  inwards  or  outwards,  ih, 

fraftures  from  a  fall,  or  a  biow,   150. 

kin'l  of  derangernent,  in  all  cases,  ih. 

diagnosis,  ib. 

in  trafturt-  wit'i  intense  straining  of  the  articulation  of  the  foot^ 
and  inflammation,  some  praftisers  confine  their  attention  to 
these  accompanying  circumstances;  dangerous  consequences  of 
this  treatment,  ib. 

—-proper  method  in  such  cases,  151. 


Analytical  iSDEx.  ^31 

\Fihula.     Continued.) 

time  of  consolidation,    151. 

treatment  of  fradlures  towards  the  middle  part  of  the  bone,  ih. 

fradlure  near  the  inferior  extremity  a  frequent  complication  of  in- 
ward luxation  of  the  foot ;  treatment,  286. 

For  fradlure  ot  both  bones  of  the  leg,  see  the  article  Leg. 

The  Luxation  of  this  bone  from  the  tibia  is  diiHculr,  but  may  oc- 
cur :  instance  ;  treatment  283.        • 
Fingers.     See  the  article  Phalanges. 

Foot  :  O  1  Fractures  of  the  Boa-rs  of;  See  the  articles  M<..'i;.'.3;v«i  ; 
Phalanges  (of  the  toes)  ;   and  Tarsus, 

luxations  of  the  foot ;  seldom  occu.-,  0:1  account  of  the  confirma- 
tion of  the  parts,  284. 

may  be  either  inwards,  outwards,  forwards  or  backwards  ;  and 
in  each  case  complete  or  incompiete;  the  two  former  diredions 
most  frequent,  particularly  the  first  ;  its  cause  and  symptoms, 
284,  285. 

— symptoms  of  the  outward  luxation,  285. 

Luxations  o(  the  foot  always  dangerous,  and  sometimes  fatal ; 
the  prognosis,  however,  not  always  so  unfavourable,  ib. 

the  reduftion  should  be  effefted  as  soon  as  possible  :  method  ;  and 
after-treatment,  ib. 

the  nature  and  violence  of  the  symptoms  decide  with  respefl  to 
amputation  ;  the  astragalus  may  in  some  cases  be  extirpated 
with  advantage  ;  instances.   286. 

frafture  of  the  fibula  near  its  inferior  extremity  a  frequent  compli- 
cation of  the  ir.ward  luxation  ;  treatment,  ib. 

causes  of  forward  and  backward  luxations  ;  the  fcrrricr  more  dif- 
ficultly produced,  ib. 

— process  of  each  ;  symptoms  of  the  backward  luxation;  hovv 
distinguished  from  sprain,  ib, 

'■ symptoms  of  the  forward  luxation,  ib, 

— redudion  of  both  species  ;  and  treatment,   287. 

The  astragalus  and  os  calcis  never  ccmpleiely  separated  by  luxa- 
tion, lb. 

—may,  however,  be  disjoined  (one  or  both)  from  the  scaphcidss 
and  cuboides,  ib. 

(— — ingeiiious  idea  of  Chopart,  of  amputating  only  a  part  of 
the  foot,  ib, 

i—- causes  of  this  luxation:  it  is  often  with  difficulty  ascertained  ; 
and  not  easily  reduced,  instance,  ih. 

the  other  bones  of  the  tarsus  and  metatarsus  cannot  be  luxated, 
288. 

See  also  the  article  Phalanges  (of  the  toes). 

Deformity  of  the  feet,  {club -foot  e'd :)  its  different  species;  cause; 
necessity  of  early  application  ;  and  treatment,   318,  319. 
Fore-arm  ;  On  Fra6lures  of,  83. 

distinction ;  into  fraclures  of  both,  or  of  only  one,  of  the  bones, 

84- 
I,  Fradtures  of  both  the  bores ;  generally  take  place  ia  the  part 
on  which  the  cause  has  immediately  afled,  ih. 


7»>fV4 


332  ANALYTICAL    INDEX-. 

(Fore-arm;  fraftares  of.     Continued.) 

the  two  bones  may  be  fraftured  on  the  same,  or  on  a  different  level ; 
the  fraftures  are  generally  complicated,  84. 

species  of  derangement :  that  in  the  longitudinal  direftion,  ex- 
tremely rare  ;  that  in  the  diredlion  of  the  diameter,  i6. 

—the  angular  derangement,  ;^. 

signs  of  frafture,  ii,       ^ 

— fradlure  near  the  inferior  extrernity,  how  distinguished  from  lux- 
ation, 85. 

jetting  the  fradlure,  ii. 

application  of  compresses,  bandages,  and  splints :  the  compresses 
and  splints  should  be  of  the  same  length  as  the  arm;  lateral 
splints  useless  and  injurious,  85. 

treatment  of  cases  of  excessive  contusion,  with  wound  or  commi- 
nuiive  fradture,  86. 

time  of  consolidation,  z^. 

2,  and  3,  Fradlure  of  the  Radius  or  Cubitus  only:  See  those  ar- 
ticles. 

Of  Luxations  of  the  fore- arm,  251. 

I,  of  Luxations  of  the  fore-arm  from  the  Humerus  ;  they  may  be 

either  backwards,   laterally,  or  anteriorly  :  the  first  the  most 

frequent ;  the  lateral  much  less  so,  and  always  incomplete;  the 

anterior  very  rare,  251. 
process  of  the  Backward  luxation,   252. 
— this  always  takes  place  from  a  fall  on  the  hand,  ii. 
—situation  of  the  parts  after  the  dislocation,  ii. 
— this  luxation  may  be  mistaken  for  fradlure  ;  instance  :  the  diag- 
nosis is  difficult,  ii. 
— different  means  of  redudlion  ;  attended  wiih  inconvenience,  253, 

a  preferable  method,  ii. 

after  treatment,  253,  254. 

— case  of  rupture  of  the  ligament  confining  the  head  of  the  radius 

to  the  extremity  of  the  ulna;  treatment,  254. 
— necessity  of  speedy  redudlion  of  these  luxations,  2^. 
luxation  Forwards ;  to  be  treated  as  a  fradlure  of  the  olecranon 

(See  that  article).   il>. 
luxation  Laterally;  method  cf  redudlion,  ii. 
— keeping   the  bones  in  their  place,  preventing,  or  mitigating, 

the  inflammation,  255. 
2,  of  Luxation  of  the  Superior  Extremity  of  the  Radius  from  the 

Ulna,  ii>. 
this  the  most  frequent  of  the  relative  dislocations  of  the  bones  of 

the  fore-arm,  il>. 
divided  into  primary  and  secondary  luxations;  the  former  class 

considered,  ii, 
— cause  of  the  backward  being  (in  this  case)  more  frequent  than 

the  anterior  luxation,  ii>. 
— state  of  the  parts  in  the  backward  luxation,  256. 

method  of  redudlion  ;  and  after-treatment,  iL 

—Secondary  luxation  ;  its  causes,  il>. 


ANAL'VTICAL    INDEX.  233 

(Fore-arm;  luxaiionsof.     Continued. 

— takes  place  frequently  in  young  children,  fiom  ihe  mischievous 
praftices  of  nurses :  treatment ;  and  consequences  ot  r.eglcd>,  256, 

257-  .  ,     '       . 

3,  ot  Luxations  of  the  inferior  Extremity  of  the  Ulna  ;  this  name 
adopted  in  preference  to  that  (u'.ed  by  other  authors)  of  Luxa- 
tions of  the  inferior  extremity  ot  the  radius,  257. 

these  luxations  may  take  place  anteriorly  or  posteriorly  ;  the  latter 
by  much  the  most  frequent,  ib. 

— process  of  the  former,  ib. 

remarkable  instance  of  this  case,  258. 

— instance  of  luxation  backwards,  ib, 

its  process,  ib. 

method  of  reduftion  ;  and  treatment,  ib. 

:his  luxation  less  inconvenient  in  its  consequences  thtn  thai 
in  the  forward  direiflion,  ib. 
Foreign   bodies   formed   in   the   artigulations  ;    to  be 
carefully  distinguished   from  arthritic  concretions  depcs'ted  in 
their  neighbcurliocJ,  293. 

may  occur  in  the  inside  ot  every  articulation  in  which  there  is  mo- 
tion, but  none  more  subjeft  to  them  than  THE   knee,  ib, 

[The  subsequent  detail  of  circunriStances  and  treatment,  applica- 
ble only  to  those  found  in  this  joint.] 

their  different  appearances,  number,  size,  form,  and  substance,  ib. 

their  origin  and  growth,  difficult  to  explain;  various  suppcsitions 
on  this  point,  294. 

their  different  symptoms,  and  circumstances,  ib. 

these  substances  cannot  be  resolved,  ncr  (with  advantage,  if  at  all) 
fixed  and  confined,  295. 

extradion  the  best  method  of  cure  ;  process  of  this  operation,  and 
after-treatment,  ib. 

Case  of  these  bodies  in  othes.  joints,  297. 
Fractures;  natural  cause  of  iheir  superior  tardiness  In  reu.     . 

beyond  that  of  wounds  of  the  flesh,  9. 
definition  of  fra£ture,   1 1 . 
See  the  articles  Causes,  Prcgmsis,  Species,   SigKS,  and  Trec/fraii, 

of  Fractures  ;   Callus  ;  and  the  names  of  the  principal  lones. 
Fragility  ;  state  in  which  this  disease  appears  in  the  bones,  107. 
it  is  a  natural  consequence  of  eld  age,  9.  lo,  197.      " 
— at  that  period  of  life  the  disease  is  incurable,   198. 
sometimes  occurs  in  adults,  from  a  venereal,   scrciulcus,  cr  cr.r. 

cerous  taint,  ib. 
— operation  of  the  last  cause  ;  remaik?ble  instances,  ib. 
— ot  the  venereal  taint ;  in  this  case  tie  primary  disease  claims  the 

chief  attention,  ib. 
—of  scorbutic  afFedions,  ib. 

■appearance  of  the  bones  of  a  scorbutic  perron,  when  boiiec, 

ib. 
conclusion;  fragility  rather  a  symptom  of  senility  cr  seme  disease, 

than  itself  a  disease;  the  etiohgyof  Rickets  may  perhsps  in 

•lime  be  elucidated  by  a  ccmpariscn  of  these  two  aJItiSiicr*,  .-1. 


;.fv''>^ 


334  ANALYTICAL    INDEX. 

Hand  ;  On  the  Frailuies  and  Luxations  of  the  bones  of.     See  tlie 
different  arciclcs  Capus,  Metacarpus  ;  and  Phalanges  of  the  fin- 
gers. 
Hanging:  different  manner  of  dying,  of  the  criminals  hanged  at  Ly- 
003  and  those  at  Paris  ;  occasioned  by  a  trivial  custom  of  the 
executioner  of  the  former  place,   227. 
Hardness:  cause  of  this  peculiar  quality  of  the  bones  ;  and  its  pro- 
gress from  infancy  to  mature  age,  9. 
Humerus  ;  On  the  FraSIures  of,  78. 

may  be  fraftured  in  any  point  of  its  length,  ih. 

the  fradtures  may  be  either  transverse  or  oblique,  simple  or  com- 
pound, ih. 

— transverse  fraftures,  78. 

— oblique  fra&ures,  il. 

gei\fral  diagnosis,  79. 

— fradlures  in  the  neck  of  the  humerus  not  so  easily  ascertained  ; 
direftions  on  this  point,  iB. 

different  degrees  of  danger,  in  fraftures  at  different  lengths  of  the 
bone,  80. 

operation  of  setting  transverse  or  oblique  fraftures;  bandage, 
&c.  ih. 

— the  bandage  must  be  applied  on  the  hand  and  fore- arm,  ih. 

positions  of  the  arm  ;  and  general  treatment,  81. 

— in  cases  complicated  with  violent  contus'on,  or  comminutive,  ih. 

position  of  the  splints,  in  fraftur^-s  of  the  lower  extremity  of  the 
humerus;  Boyei's  praftice,  82. 

particular  treatment;  in  fraflures  of  the  neck  of  the  humerus,  ih. 

— M'jscati's  method  ;  its  great  disadvantage,  ih. 

— corredled  by  Le  Dran,  ih. 

— further  improved  by  Desaulr,  ih. 

———eminent  merit  of  this  Improvement,  83. 

treatment  of  a  case  sometimes  happfning  in  young  subjects,  of  the 
head  of  the  humerus  (while  yet  but  an  epiphysis)  separating 
from  the  rest  of  the  bone  by  a  blow  or  fall,  ih, 

compound  fradlures  not  to  be  sec  till  the  inflammation  has  sub- 
sided, ih. 

Of  Luxations  of  the  Os  Humeri,  239. 

equal  in  ftequency  the  luxations  or  all  the  other  bones,  ih. 

may  take  place  in  three  direftions ;  downwards,  inwards  or  for- 
wards, and  outwards  or  backwards :  luxation  upwards  is  impos- 
sible, ih. 

— the  luxation  even  outwards  or  backwards'^scarcely  occurs ;  the 
other  two  species  therefore  merit  chief  attention,  239.  ' 

the  downward  direftion  more  frequent  than  the  inward  or  forward  ; 
and  in  that  case  a  subsequent  change  of  place  m?y  carry  the 
head  of  the  humerus  in  this  latter  diredlion,  but  cannot  carry  it 
backward,  240. 

I,  Consideration  of  the  downward  luxation:  causes  which  render 
this  the  most  frequent  diredion,  ih, 

manner  in  which  this  luxation  is  performed,  elucidated,  241. 

it  has  been  thought  that  when  the  arm  is  moved  out  from  the  body, 


ANALYTICAL    INDEX.  ^3$ 

(Humerus;  luxations  of.     Continued.) 

the  aflion  of  the  deltoid  muscle  alone  can  produce  a  dislocation  ; 

case  cited,  iB* 
state  of  the  parts  when  the  luxation  has  taken  place,  242. 
diagnosis ;  marks  by  which   the  downv.ard  luxations  are  distin- 
guished from  fraclares  of  its  neck,  79,  242,   243.  , 
prognosis,  uncertain,  243. 
means  toefFedl  redudlion  ;  enumeration  and  description  of  various 

which  have  fallen  into  disuse:  the  amBe  of  Hippocrates,  i5. 
— the  ladder,  ih, 
—the  prucess  by  the  door,  244. 
— Petit's  machine,  ih. 
— the  patient  and  the  surgeon  both  extended  on  the  floor,  &c.  il. 

^ or  seated  opposite  one  anoiher,  &c.  ih. 

a  more  umxceptionable  method,  244,  2/^.5. 

-—if  the  first  attempts  fail,  bleeding  and  warm  bathiRg  and  repeat 

the  operation  ;  in  no  circumstances  pullies  or  other  extending 

machines  to  be  employed,  245,  246. 
useless  and  exquisite  torture  produced  by  the  adoption  of  such 

mechanical  contrivances,  246. 
erroneous  supposition  that  the  narrowness  of  the  opening  through 

which  the  head  of  the  humerus  has  escaped  resists  its  redudlion, 

ih, 
method  of  reduction  after  a  certain  interval  has  elapsed,  217,  246. 

2,  Luxation  inwards  ;  may  be  primary  or  secondary,  247. 
erroneous  opinion,  that  the  head  of  the  humerus  may  be  carried 

upwards  towards  the  clavicle,  and  be  placed  between  the  great 

peftoral  muscle  and  the  subscapularis,  ih. 
diagnosis,  ii, 

prognosis;  more  unfavourable  than  in  downward  luxation,  248. 
— means  of  reduftion,  nearly  the  same  as  in  this  latter,  ib. 

3,  Luxation  outwards  or  backwards;  no  well-attested  instance  of 
this  exists,  though  it  appears  to  have  been  admitted  possible,  ih. 

cannot  take  place  secondarily,  and  succeed  to  a  luxation  down- 
wards, ih. 

diagnosis,  in  the  event  of  its  occurrence,  ih, 

•^means  of  reduftion,  ib. 

General  treaiment  of  each  species  :  means  of  keeping  the  reduced 
bone  in  its  place,  ib. 

topical  applications  if  necessary,  in  contusions  of  the  shoulder; 
emoliients,  bleeding  (in  certain  cases),  and  resolvents,  249. 

:— in  oedema  of  the  arm  ;  its  causes ;  seldom  occurs,  ib. 

' — in  paralysis;  different  treatment  according  to  its  different  causes, 
ib. 

•        sometimes  confined  to  the  deltoid  muscle,  il. 

Tumour  sometimes  produced  by  the  violent  tfFurts  necessary  to  re- 
duce an  old  luxation  ;  its  nature,  250. 

Anchylosis  never  a  consequence  of  luxations  of  the  humerus  when 
reduced,  and  even  rarely  when  they  are  not  reduced,  2:;o. 

Method  of  cutting  ofFthe  carious  extremity  of  this  bone  (wiien  the 
state  of  the  soft  parts  will  admit  of  it)  in  the  case  of  white 
swelling,  308. 

instance;  309. 


^2^  ANALYTICAL    INDEX. 

I/ia  (ossa),  fra£lurcs  of.     Sec  the  following  article. 
Innominata  ossa  ;  ihese  bones  seldom  fra6iured,  66. 

the  fradlure  may  occur  in  different  parts  of  them,  and  take  diffe- 
rent directions,  ib.  ' 

no  derangement  of  the  portions  ever  takes  place,  ii, 

these  fraftures  rendered  very  dangerous  by  extravasation  and  con- 
tusion, ib. 

their  signs,  ib, 

treatment,  ib. 

— apparatus  by  which  the  patient  may  raise  himself  in  bed,  6j. 

the  inflammation  gen  rally  produces  suppuration  and  abscesses,  ib. 

detached  splinters  sometimes  give  rise  to  subsequent  abscesses,  ib. 

treatment  if  the  bladder  is  perforated  by  a  splinier,  :b. 

These  bones  are  too  firmly  articulated  to  admit  of  'Luxation  ;  the 
articulations,  however,  may  be  rehxed  to  a  certain  degree,  230. 

question  whether  this  relaxation  is  a  means  fmployed  by  nature  to 
facilitate  parturition,  ib. 

— when  the  relaxation  goes  so  far  as  to  allow  the  bones  to  be  moved 
and  separated,  it  is  rather  a  morbid  than  a  natural  state,  ib. 

—instance  of  fatal  sudden  and  easy  delivery ;  appearance  of  the 
ossa  pubis  and  symphysis  on  dissection,  231. 

treatment  in  relaxation  of  the  symphysis  pubis,  or  of  the  sacro-iliac 
synchondrosis,  231. 

—a  sudden  and  violent  separation  of  the  thighs  not  capable  alone 
of  producing  a  disjointing  of  the  latter,  ib. 

this  may,  however,  be  occasioned  by  external  violence,  in- 
stance, 232. 

these  cases  must  be  very  rare:  proper  treatment;  the  anti- 
phlogistic, ib. 
Ischia  (cisa).     See  the  preceding  article. 
Jav/.     See  Lev/ er  jaw, 

Kne  E.     See  the  article  Dropsy  of  the  articulations;  Fo- 
reign   BODIES    FORMED     IN    THE    ARTICULATIONS;    and 

White  SWELLINGS.  .     •.- 

Deformity  of  this  part  (of  being  turned  inwards  or  outwards)  fre- 
quently induce  in  children  by  the  practice  of  too  early  walking; 

simple  and  efficacious  method  of  remedy,  317. 

Leg;  Cii  the  i"/-^c7«;rj  of,    143. 

this  name  comprises  those  traflures  only  in  which  both  bones  are 

broken  ;  the  middle  of  each  is  the  part  generally  fradured,  ib. 
in;'.y  he  either  transverse  or  oblique;  and  arc  liable  to  every  sort 

ci" derangement,  ib. 
diagnosis,   144. 
prognosis,  varies  according  to  many  circumstances ;  fraflures  near 

the  kaec,  or  the  inferior  part,  more  dangerous  than  of  the  aiid- 

dlf;  oblique  fraClures  very  difficult  to  be  managed,  ib. 
treatment  of  simple  fradtures :  disposition  of  the  patient;  appara- 

tus,  and  its  application  ;  bleeding,  and  low  regimen,  144,  145. 
— -coaipresfcs  under  the  lieel,  not  to  be  prnflised,  145. 


ANALYTICAL    INDEX.  J37 

(Leg  ;  fra£lures of.     Con t i nued . ) 

— roller,  for  very  young  children  only,   145. 

—the  apparatus  should  be  re-applied  at  the  end  of  eight  days,  and 
afterwards  every  seven  days ;  dangerous  praftice  of  not  changing 
the  first  dressing  for  eighteen  or  twenty  days,  ib. 

— time  of  consolidation,   146. 

— regimen,  &c.  ih. 

in  verv  oblique  fradtures,  continued  extension  should  be  employed, 
ib, ' 

For  frafiures  of  either  bone  singly,  see  the  articles  Fibula',  and 
Tibia  ;  And  for  luxations  of  the  Bones  of  the  Leg,  see  also  those 
two  articles. 
Longitudinal  fraBures,  an  inadmissible  distin£lion,   13. 
Lower  jaw;  kinds  of /'ra^SFwrs  to  which  it  is  liable  j  and  their  me- 
thod of  producing  the  effeft,  48. 

variations  as  to  the  part  of  the  bone  fraftured,  ib. 

-^as  to  thedireftion  of  the  frafture,  ib. 

these  fradtures  seldom  simple,  49. 

-^causes  producing  the  derangement  of  the  fraftured  portions;  the 
complicated  disposition  and  adlion  of  the  muscles,  ib* 

symptoms  of  frafture,  50. 

:■ — in  the  branches  and  condyles,  ib. 

these  fraftures  in  general  not  dangerous,  il. 

— compound  fraftures,  however,  are  so,  ib. 

operation  of  setting  a  simple  or  double  frafture,  51. 

great  difficulty  of  maintaining  the  fragments  in  the  just  position  ; 
particularly  of  keeping  the  jaw  motionless,  on  account  of  its  na- 
tural funftions,  ib, 

^—methods  of  feeding  the  patient,  in  this  latter  view,  ib. 

—ligatures  of  gold  or  silver  wire,  unnecfessaryi  and  not  of  general 
utility,  ib, 

'' — pasteboard  moulds  injurious,  51, 

— the  use  of  bandages  preferable  ;  method  of  applying  them,  52. 

• -modiiicatioii  of  this  apparatus  required  ih  fracture  of  the  con- 
dyles, 52. 

particular  inrtportance  in  frafturcs  of  the  condyles  ro  obtain  a  cure 
without  deformity  :  ieffefts  of  perverseness  in  the  patient  during 
the  treatment ;  instance,  52. 

period  of  cure,  53. 

fradture  with  violent  contusion,  or  it  division  bf  the  soft  parts,  53. 

On  Luxations  of  the  Lower  Jaw;  the  distinftion  into  complete  and 
incomplete  is  erroneous,   220. 

these  luxations  can  take  place  only  anteriorly,  ib. 

• — in  very  young  infants,  they  are  impossible  in  any  direftion,  ib. 

the  causes  are  almost  always  internal  ;  as,  from  excessive  yawn- 
ing, 221. 

processof  the  luxation,  ib. 

—theory  of  the  mode  in  which  it  is  effedled  ;  ill-founded,  j3. 

•——a  much  better  theory  on  this  subjedl,  iB. 

43 


<*'i-^:.    .   •'T'^s 


33^  ANALYTICAL    INDEX. 


(Lower  jaw;  luxations  of.     Continued.) 

macnjr  in  which  the  parts  surrounding  the  articulation  are  affcft- 

ed,    222. 

diagnosis,   z^. 

— these  appearances  much  less  distinfl  when  a  certain  interval  has 
elapsed,  223. 

prognosis :  much  less  unfavourable  than  that  established  by  Hip- 
pocrates ;  and  not  the  more  so  in  persons  in  whom  the  luxation 
is  made  with  facility,  ih. 

mode  of  le 'u^ion,  ih. 

— after-treatment,  224. 

method  of  reducing  the  luxation  by  fatiguing  the  muscles,  224. 

censurable  pradice  of  reducing  these  luxations  by  a  bluw  o)  the 
fist,  i6. 

pradticc  of  ihe  ancients,  of  u<;ing  pieces  of  stick  as  levers  between 
the  great  mnlarr s,  to  depress  the  lower  jaw ;  the  modern  pro- 
cess preferable,  il>. 

In  dislocations  of  one  condyle  only,  little  modification  of  the  treat- 
ment is  required,  i6. 
Luxation:  rarely  accompanies  Fradures,   17,  32. 

—question  of  the  treatment  of  such  cases  when  they  occur  ;  whe- 
ther the  dislocated  fragment  should  be  Jirst  replaced,  or  not,  till 
the  consolidation  of  the  frafture  is  efFeitei,   32. 

the  head  of  a  luxated  btine  may  be  mistaken  for  exostosis;  instance, 
in  dislocation  of  the  clavicle,   178. 

Luxation  described :  divided  ^nto  complete  and  incomplete,  204. 
the  previous  anatomical   knowledge  necessary  to  consider  the  na- 
ture of  tbis  afi^edlion,  iB. 
luxations  afford  both  general  and  specific  characters,  il>.  ^ 

See  the  articles  Diffcrenca  ;   Sympioms  ;  Prognosis ;  and  Treatment. 

Metacarpus :  fractures  of  these  b?  nes  rarely  occur,  93. 

the^e  Iradures  always  caused  by  a  force  immediately  applied  ;  al- 
most in  all  cases  several  of  the  bones  are  fraftured  at  once,  ib, 

— case,  h.vvever,  of  a  f^adure  of  a  single  o'e,  94. 

comiTiinutive  fra£lure  frequently  renders  amputation  necessary,  ih. 

These  bones  are  never  luxated :  the  ligaments  of  their  articulations 
may,  h  vvever,  be  torn;  treatment,  261. 

different  liability  of  each  bone  to  Inxation,  262. 
Metatarsus  \  the  bones  of,  susceptible  only  of  comminutive_/r«<!7«rf, 
154. 

treatment,  the  same  as  those  of  the  Hand,  93,  154. 

These  bones  cannot  be  luxated^  288. 
Muscles :  their  powerful  effodls  in  the  derangement  of  the  fradured 
portions  0^  a  bone,   15. 

three  d iff- rent  cases  of  this;  all  instanced  in  the  muscles  of  the 
thigh,  ib. 

I,  c^se  of  muscles  attached  to  both  the  portions;  instances,  ib, 

2,  muscles  inserted   into  the  lower  portion,  or  the  limb  with 

which  it  articulates ;  instances,    16. 

—3,  muscles  inserted  into  the  superior  fragment;  instance,  ib. 


ANALYTICAL    INPEX.  339 

Negk  of  the  femur  ;  On  the  Fra£luresol^  ic2. 

these  tradturet>  most  frequently  take  place  in  its  middle  part ;  ex- 
ist within  the  articulation ;  and  are  almost  always  transverse, 

ib. 
—another  species,  which  takes  place  outside  the  articulation,  near 

the  union  of  the  bone  with  its  trochanters,  and  sometimes  be- 
tween these  two  eminences,  ib, 
— instance,  of  fra£lure  below  the  orbicular  ligament,  ib. 

remarkable  instance,  of  a  double  fradure,   one  inside  and 

one  outside  that  ligament,   103. 
frafture  of  the  neck  of  the  femur  sometimes  complicated  with  that 

of  the  great  trochanter,  very  rarely  with  contusion  ;  may  be 

comminutive,  from  a  gun-shot  wound,  ib. 
case  or  decollation  of  the  epiphysis,  ib. 
— progress  of  os5ification  in  the  superior  extremity  of  the  femur, 

from  infancy,  ib. 
— possibiliiy  of  this  species  of  dlsjunclion  in  the  early  part  of  life; 

its  diagnoois,  treaiment,  and  prognosis,   X03,    104, 
predisposing  causes  of  these  fradures ;  briitieness  of  the  bones, 

vices  ot  the  constitution,  caries,  rickets,   104. 
- — ven-real  d.s-ase,  ib. 
exciting  causes:  a  fall  on  the  great  trochanter;  or  a  fall  on  the 

feet  or  kr.ees,   104,    j©5. 
—manner  in  vvhicii  the  tradure  is  produced  in  each  of  these  two 

cases,   105. 
these  fractures  are  never  direft,  but  the  contusion  may  nevertheless 

be  considerable,  ih. 
always  attended  with  derangement,  though  this  may  not  ensue  for 

several  days  after  the  fradture,  ib. 
—the  delay  in  this  circumstance  may  be  produced  by  the  resistance 

of  the  orbicular  ligament,  or  of  the  roughness  of  the  surfaces  of 

the  pieces,   102,   106. 
— Jerangemcnt  in  fractures  within  the  articulation,  and  in  those 

outside  it,   106. 
—causes  of  drrangement ;  the  weight  of  the  body,  but  principally 

muscular  aftipn,  ib. 
— derangement  in  the  circumference;  that  in  an  outward  diredlion, 

caused  by  the  weight  of  the  part,   107. 

that  in  an  inward  diret^tlon :  its  cause ;  its  possibility  ascer- 
tained by  observations;  its  proportion  to  the  outward  direftion, 

ib. 
Diagnosis;  resemblance  ofjhe  symptoms  to  those  of  luxation,  has 

occasioned  frequent  mistakes,  ib. 
the  sensible  signs  alone  t'  be  depended  upon,   ic8. 
— the  shortening  of  ths  limb;  cautions  in  ascertaining  this  sign, 

ib, 
— position  of  the  foot,  the  knee,  and  the  leg,  ib. 
——of  the  heel ;  seldom  placed  so  high  as  above  the  ankle  of  the 

o:her  foot,  ih. 
—restoring  the  limb  to  its  natural  length  and  dlreftion,  and  the 

foot  to  its  position  ;  sensible  signs  observed  in  those  operations, 

(crepitation,  which  is  audible  in  the  former  ;  and  diminution  of 


w- 


,'J40  ANALYTICAL    INDEX. 


(NecK  OF  THE  femur:  its  fffk^lures.     Coniinued.) 

the  arch  described  by  the  great  trochanter,  in  the  latter),  io3, 
109. 

— alierattons  in  the  appearance  of  the  trochanter  and  of  the  but- 
tock, in  fradure  outside  the  articulation,   109. 

—impossibility  ot  raising  the  member  all  at  once,  a  constant  sen* 
sible  sig),   log. 

—a  distinctive  si^n  proposed  by  Louis;  unfounded,  and  otherwise 
inadmissible,   no. 

the  signs  by  which  the  different  species  of  luxation  may  be  distin- 
guished iroax  fracture  ;   ;,  luxation  upward  and  outward,  ii>. 

——2,  luxaiiun  n.ward  and  upward,  il>. 

—3,  luxations  downward,  16. 

•^4,  the  secondary  or  spontaneous  luxation,  ii. 

»— tradures,  however,  with  very  little  cr-no  derangement  some- 
times diflicuit  tu  be  abcertained  or  distinguished  ;  instance,  in. 

recapitulation  of  the  distindive  sensible  signs  oi  fradure,  i6. 

when  doubt  is  entertained,  the  apparatus  should  be  applied,    112. 

l*rognosis,   verv  difficult  to  e»tabiish,  li. 

differences  of  opinion  on  that  subjed ;  importance  of  a  right  deci- 
sion on  these,  as  it  will  dired  the  w'aole  treatment,  ii, 

1,  opinion  of  those  who  affirm  that  the  consolidation  of  the  fradure 
cannot  be  at  all  effeded  ;  arguments  01  the  assertors  of  an  os- 
seous juice  (see  p.  36),  and  of  ttie  favourers  of  Duhamei's  the- 
ry  (see  p.  37)  :  both  ttiese  parties  answered,  by  fads  and  expe- 
rience, 112,   113. 

—argument  founded  on  a  want  of  a  sufficient  degree  of  vitality  in 
the  superior  fragment ;  atiswered,  by  the  insiaices  relied  on  for 
its  support  having  bef  n  drawn  from  cases  of  the  complete  rup- 
ture of  the  orbicular  ligament,  or  of  old  age,  39,   113,   114. 

2,  opinion  of  those  who  affirm  that  the  shortening  of  the  limb  can 
by  no  means  be  preven:ed  ;  their  different  theories  on  the  cause 
of  this  supposed  inevitable  consequence.   114. 

— writers  by  whom  this  opinion  has  been  adopted  :  cojitradided  by 
many  instances;  one  adduced,   115. 

conclusion,  ii. 

Motion  of  the  parts  to  be  particularly  avoided  during  the  treat- 
ment of  these  fradures,  as  tending  to  retard  the  naturally  slov^ 
formation  of  the  callus  there,   1 16. 

Principal  objeds  to  which  the  attention  should  be  di reded  in  treat- 
ing these  fradures:  i,  setting  the  bone;  application  of  the 
united  force  of  several  assistants  iitfeffeding  extension,  ii. 

—previously  to  extension,  the  derangement  in  the  circumference 
should  becorreded,  i6. 

—coaptation  totally  useless,  ii>. 

—treatment,  if  on  the  f^rst  attempt  at  extension  the  muscles  con- 
trad  powerfully,   117. 

3,  keeping  the  pieces  in  their  place  ;  difficulty  of  this  point,  i6. 
— (question  of  the  position  considered;  the  half- bent  state  to  be 

t'>tally  rejeded  ;  proper  position,  16. 
— numerous  contrivances  for  this  purpose;  examination  of  these  : 
(Srit)  of  those  which  do  not  effcd  any  extension,  iL 


ANALYTICAL    INDEX.  34I 

(Neok  OF  THE  femur;  its  fraftures.     Continue-'.) 

—— —ihe  spica  bandage  of  the  groin,   iiS. 

..  -the  eighteen-taiicd  bandage,  as&i&Ced  by  the  fanons  or  faux- 
fanons,  ib. 

• long  splints ;    and  some  other  expedients :    all  inefFedlual, 

118,   119. 

——method  of  Foubert ;  by  continual  resetting,   119. 

method  of  Brunninghausen,  iS. 

— (secondly)  contrivances  for  efFecli.ig  perpetual  extension  ;  their 
application,  and  purpose,   120 

—the  bed  of  Hippocrates  j  and  the  Glosscomcn  used  by  the  an- 
cients, ii. 

method  of  Avicenna  and  others,  of  fastening  the  bands  for 
extension  to  the  head  and  foot  of  the  bed,  120,  121. 

—use  of  a  pulley  and  weight,   121. 

machine  of  BeUocq,  ii. 

machine  of  Hook,  perfefted  by  Aitken,  ii. 

——particular  account  of  Desauh's  apparatus;  and  its  applica- 
tion,   122,    123.      Its  disadvantages,   124,    125. 

— —improved  and  perfect  apparatus  of  Boyer  described  ;  and  its 
application,   125,   126. 

—— -cautions  in  the  use  of  the  two  last,   1 26. 

3,  removin;!  any  unfavourable  symptoms:  topical  applications: 
contusion  and  violent  inflammation  ;  regimen,  ii. 

Question  whether  in  these  fradlures  internal  remedies  ought  to  be 
resorted  to  for  accelerating  the  consolidation  ;  as,  rich  gelatinous 
food,  osteoci'lla,  or  spirituous  liquors,    126  to  128. 

—nourishment  easy  to  digest,  and  spirits  in  moderate  quantities, 
useful,  128. 

time  of  consolidation,  ii. 

a  stiffness  in  the  articulation  not  much  to  be  apprehended,,. /5. 

in  some  cases  the  improved  method  cannot  be  adopted,  i5. 

consequences  which  would  follow  if  the  patient  were  abandoned  to 
nature,  129. 

For  its  Luxations,  see  the  article  Femur. 
NscROSis  :  striilly  analogous  to  gangrene  of  the  soft  parts;  essen- 
tially different  from  caries,   157  to  164. 

bones  which  it  most  frequently  attacks  ;  it  may  be  either  partial, 
or  extend  to  the  whole  substance,   157. 

of  long  bones,  the  middle  part  is  most  subjeA  to  it ;  and  never  the 
articulations,   158.  ' 

when  the  necrosis  is  superficial,  the  superior  lamellae  are  separated 
after  a  suppuration,  ih. 

progress  of  the  afiadlionin  a  broad  bone,  ib. 

— in  complete  necrosis  of  a  long  bone,  ib. 

separation  of  the  periosteum  from  the  diseased  portion  ;  this 
is  analogous  to  the  process  of  mortification  in  the  soft  parts,  but 
is  performed  much  more  slowly,   159. 

causes  of  necrosis ;  internal,  and  external,  ib. 

general  diagnosis,  160. 


z^- 


w 


J42  ANALYTICAL   INDEX. 


(Necrosis.     Continued.) 

prognosis ;  varies,  according  to  the  bone  affedled  and  to  circum- 
stances of  coinplicaiion,   160. 

—in  partial,  and  in  large,  affeftions  of  flat  or  long  bonf^s,  ib. 

—in  cases  where  the  dead  bone  is  entirely  included  in  thac  newly 
tormel,  ib. 

in  this  affedioa  nature  must  be  left  to  her  own  operations ;  the  as- 
sistance of  art  is  confined  toexiratting  the  dead  portions,  161. 

treatment  in  necrosis  oi  broad  or  flat  bones;  as,  one  of  the  large 
bones  of  the  skull,  ih. 

——jne  of  the  c;snes  of  the  cranium,   162. 

— of  tile  exterior  lamellae  of  a  long  bone,  the  same,  ib. 

— in  necrosis  of  the  eatire  body  of  a  long  bone,    163. 

■he  ex'traflion  of  the  dead  bone  from  within  the  ossified  peri- 
osteum in  ihis  case,  is  a  painful  and  h^izurdous  process,   163. 

method  of  performing  this  operation,  when  determined  on, 

ib. 

should  not  be  had  recourse  to  without  the  most  mature  delibe- 
ration,  164.  • 
Nose;  the  bones  of,  much  exposed  to  Fradlure,  46. 

most  frequent  kinds  of  fradures,  ib. 

case  where  the  soft  parts  are  not  divided,  nor  the  fragments  dis- 
place!.^, ib. 

comminutive  fradure ;  treatment,  and  operation,  for  its  re-estab- 
lishment, 47.    ' 

—in  this  fradlure  with  depression  of  the  splinters,  the  fragments 
should  be  adjusted  without  waiting  the  disappearance  of  the  in- 
flammation, ib. 

fraftuie  of  these  bones  sometimes  attended  with  very  da-^gerous 
symptoms,  ib. 

— tnis  etiology,  however,  applicable  only  to  persons  advanced  in 
age,  ib. 

Oblique  fraSiure  defined ,  12. 

more  dangerous  than  the  transverse  ;  the  greater  the  obliquity,  the 

greater  the  danger,  22. 
Olecranon :  analogy  between  the  fraftures  of  this  bone  and  those  of 

the  patella,  89. 
— the  former  almost  always  occur  at  its  base,  and  most  frequently 

from  some  external  force,  ib. 
signs  of  these  fraftures,  90. 
—may  be  thus  easily  distinguished  from  a  luxation  of  the  cubitus 

backward,  ib. 
treatment ;  application  of  compresses,  bandages,  &c.  90  to  91. 
time  of  re-establishment;  gentle  motion  to  be  commenced  earlier, 

91- 
grievous  nature  of  compound  fraftures;  treatment,  ib. 

protracted  inflammation,  92. 

Osseous  juice ;  an  effusion  of,  supposed  by  the  ancients  to  be  the  efH- 
cieat  cause  of  the  consolidation  of  fractures,  36,  37. 

OsTEO-SARCOMA  :  different  specics  into  which  this  disease  Is  some- 
times divided,  182. 


ANALYTICAL    INDEX.  343 


(OsTEO-SARCOMA.     Continued.) 

1,  the  osteo-sarcoma,  peculiarly  so  called,   183. 

2,  the  spina  ventosa,  or  poedarthrocace,  ii. 
general  diagnosis,  iB. 

each  species  is  usually  dangerous ;  effect  of  venereal  affections  in 
producing  it;  swellings  of"  the  phalanges  of  the  fingers  and  toes 
are  the  least  dangerous,  ii. 

the   treatment  in   aggravated  cases;  amputation,  if  practicable, 

in  the  real  osteo-sarcoma,  even   ampution  may  be  ineffectual  to 

prevent  a  return  of  the  affection,  i5. 
f«m  trkable  instance  of  the  second  species ;  in  the  conversion  of  the 

bones  and  surrounding  parts  into  a  gelatinous  mass,  18410  187. 

Pare,  Ambrose;  his  case,  of  a  complicated  fracture  cf  the  leg,  15. 
Patella;  the  FraElures  of,  may  be  either  transverse  or  obliqae, 
129. 

the  transverse  frequently  occasioned  by  contraction  of  the  extensor 
muscles  of  the  leg,  il, 

— expla^tion  why  that  cause  does  not  rather  rupture  the  tendon 
of  the  extensors  of  the  leg,  and  the  inferior  ligament  of  the  pa- 
tella, ih, 

——this  effect,  in  reality,  is  sometimes  produced;  but  the  symp- 
toms, prognosis,  indications,  and  treatment,  are  the  same  in 
both  cases,    130. 

•i— illustration  of  the  manner  in  which  the  fracture  of  the  patella  is 
caused  by  these  contractions ;  as,  ip  the  effort  to  resist  falling, 
ih. 

— the  same  violent  contraction  may  be  produced,  and  accompanied 
by  the  same  effects,  in  leaping,  and  other  exertions,   130,    131. 

fracture  occa?ioned  by  falling  on  the  knees,  or  by  the  violent  im- 
pulsion of  a  body  against  the  patella,   131. 

transverse  fractures  always  attended  with  a  separation  of  the  frac- 
tured portions,  though  tl'is  may  not  immediately  lake  place  5 
remarkable  instance,  ih. 

— this  separation  is  produced  by  the  concurrence  of  two  causes  ; 
the  contraction  of  the  extensor  muscles,  and  the  flexion  of  the 
.leg,   132. 

Diagnosis,  very  easy  :  as,  falling  without  the  power  of  rising,  or 
of  moving  (when  raised  by  others)  except  backward  by  draw- 
ing the  feet  along  the  ground  ;  instance,  and  treatment,  ih. 

further  signs:  depression  (instead  of  prominence)  on  the  anterior 
part  of  the  knee  ;  alterations  producible  in  the  relative  position 
of  the  fractured  portions,    133. 

Consolidation  of  these  fractures:  question  whether  this  is  effected 
by  immediate  reunion,  or  by  means  of  a  ligamentous  substance, 
ih, 

authorities  by  which  the  latter  theory  is  sanctioned,  ih. 

the  arguments  for  the  former,   134. 

an  instance :  the  theory  of  the  intervention  of  a  ligamentous  sub- 
stance is  well  founded,  ib. 


viiJ.? 


344  ANALYTICAL    IKDEX. 

(Patella.     Continued.) 

the  organization  of  the  patella  is  in  no  nanner  different  from  that 
of  other  bones,  and  the  peculiarities  in  the  consolidation  of  its 
fractures  arise  from  merely  mechanical  causes   135. 

erroneous  supposition  of  Cillisen  as  to  the  'mpediment  to  reunion 
of  the  fragments ;  its  sole  occasion  is  in  fact  the  impossibility  of 
keeping  them  in  contact  by  a  proper  apparatus,  ib. 

nnture  of  this  ligamentous  substance,   I  36. 

—when  it  is  long,  it  diminishes  the  muscular  aflion,  and  the 
strength  of  the  knee  ;   instance?,  ib. 

Objefts  of  attention  in  the  treatment;  the  principal  is,  the  dimi- 
nution of  the  interval  between  the  pieces,   137. 

previous  means  to  prevent,  or  remove,  inflammation:  i,  the  pre- 
ventatives, ib. 

•~2,  the  remedies :  immersion  in  cold  water,  useful ;  leeches,  in- 
jurious; wet  compresses,   137. 

in  cas'-s  of  excessive  contusion,    138. 

application  of  the  apparatus  when  prafticable :  1,  position  of  the 
limb,   139. 

-——position  alone,  without  confining  the  pieces,  is  insufficient,  it-. 

—2,  bandages  ;  that  in  the  form  of  a  figure  8  is  inconv'Jnicnt  anii 
injurious,  ib. 

•  •      principles  of  a  proper  bandage,    140. 

' its  application,   140,    141. 

•—some  advantage  might  be  drawn  from  a  knowledge  of  the  nume- 
rous exploded  apparatus,    141. 

—•another  apparatus  described,  consistin£^  of  a  trough.  Sec.  ib. 

— method  of  some  authors,  to  use  no  sort  of  bandage,  but  permit 
the  ligamentous  substance  to  be  lengthened  ;  mischievous  efTefts 
of  this  treatment,    142. 

0[  Luxations  of  this  bone  ;  may  take  place  in  four  dire£llons,  278. 

i ,  downwards  ;  this  can  exist  only  with  a  transverse  rupture  of  the 
tendon  of  the  extensor  muscles  of  the  leg,  ib. 

2,  upwards;  this  may  depend  on  a  rupture  of  thft  inferior  liga- 
ment of  the  patella,  278. 

3,  inwards;  and  4,  outwards:  a  predisposition  to  these  may  be, 
a  great  relaxation  of  the  inferior  ligament ;  instance,  279. 

—of  these  two,  the  Outward  is  the  most  frequent ;  its  cause,  //>. 

it  may  be   favoured  by  a  depression  of  the  external  condyle 

of  the  femur;  instances,  ib.ri 

instance  of  luxation  in  this  direftion  occasioned  by  a  gun-shot 

H'ound,  ib. 

——in  this  luxation  the  bone  is  easily  replaced,  but  difficultly 
kept  in  its  situation,  280, 

the  outward  luxation  may  be  either  complete  or  incomplete: 

it  is  seldom  complete  :  instances,  however,  ib. 

symptoms,  an!  process,  of  outward  luxation,  ib. 

— Inward  luxation  ;  its  symptoms,   281. 

Complete  luxations  cnn  occur  only  in  certain  circumstances,  ib. 

In  every  species,  reduction  to  be  eiTeifled  as  soon  as  possible  ;  me- 
thod, ib. 

— symptoms  of  redu£\ion  ;  and  afrer-treatmefit.  ib. 


.:■■  %^  •. 
ANALYTICAL    INDEX.  345 

Pelvis:  On  t\it  Fraciures  of  the  bones  of,  64. 

See  the  articles  Coccygis ;  Innom'tnata  ossa  ;   a;.d  Sacrum. 

artificial  m^ans  are  ot  small  effefl  in  thrse  fraduresj  and  even  ge- 
neral treatment  not  always  efficacious,  6j. 

None  of  the  assemblage  of  bones  which  form  the  Pelvis  are  suscep- 
tible of  a  true  Luxation :  S  e  however,  on  this  subjed,  the  above- 
mentioned  three  articles,  and  also  the  a-ticle  Ribs. 
Periosteum :  theory  which  attributes  to  this  membrane  the  consolida- 
tion of  fradlures,  37. 
Periostosis  ;   a  species  of  exostosis,    176. 

its  distinguishing  marks,  from  those  of  that  disease  stri£lly  so  call- 
ed, ib. 
Phalanges  of  the  Fingers  :  t\it  fracture  of  these  bones  always  attended 
with  contusion  ;  signs  ot  fradure,  94. 

longitudinal  derangement  very  rare  ;  the  horizontal  is  almost  the 
only  one  observed;  operations  of  setting,  and  dressing,  95. 

time  of  re-establishment,  ib. 

treatment  in  cases  of  the  extremities  being  crashed,  or  braised  by 
a  folding  door,  ib. 

— if  the  last  phalanx  alone  is  crushed^  much  better  to  amputate  at 
once,  ib.  -.    .      , 

oi  luxations :  the  first  phalanges  may  be  luxated  backwards,  but  not 
forwards,  262. 

luxations  inwards  can  occur  only  in  the  first  phalanges  of  the  thumb 
and  little  finger ;  outwards,  in  the  first  phalanx  of  the  thumb 
alone,  263. 

this  last-mentioned  phalanx  the  most  exposed  to  luxations  back- 
wards ;  their  process,  and  signs,  ib, 

their  prognosis,  ib. 

these  luxations  should  be  quickly  reduced ;  method  of  opera- 
tion proposed  by  Desault  in  a  case  of  this  kind,  ib. 

■ the  reduftion  not  so  easy  as  might  be  imagined,  ib. 

method  of  rcdudion  in  various  of  these  luxations ;  and  after-treat- 
ment, ib. 

See  also  184,  303. 

phalanges  of  the  Toes ;  susceptible  only  of  comminutive  fraSlurc, 

154.  ■- 

treatment,  the  same  as  those  of  the  fingers,  ib, 
cannot  be  luxated  hy  external  violence,  288. 
—but  the  first  phalai^x  of  the  great  toe  may  be  luxated  from  the 
first  bone  of  the  metatarsus ;  treatment,  ib. 
Paedarthrocace      See  the  article  Osteosarcoma. 
Position  of  a  fradlurcd  limb  during  cure,  25. 

Pregnancy ;  does  not  perceptibly  retard  the  consolidation  of  a  fradure, 
23,  40. 
relaxation  of  the  articulations  of  the  ossa  innominata  during  preg- 
nancy :   See  the  article  Innominata  ossa  (luxations ) . 
Pyognosis :  of fraSures  ;  different  according  to  various  circumstances; 
as,  the  bone  tradured,  the  part  of  the  bone,  and  the  diredion  of 
the  fradure  ;  instances  of  each,  21,  22. 
- — according  to  the  points  ot  complication,  22. 
41 


34^  ANALYTICAL    INDEX. 

{Prognosis.     Continued.) 

— accordlngjto  the  health  and  age  of  the  individual ;  instances,  zz. 

In  Luxation:  dislocations  in  the  round  articulations  much  less  dan- 
gerous than  in  the  ginglymoidai,  211. 

the  difficulty  of  reducing  the  luxated  bone  renders  the  luxation 
more  or  less  troublesome,  ib. 

luxations  arising  from  certain  distempered  occasions  have  worse 
consequences  than  those  trom  external  violence  ;  and  if  accom- 
panied with  particular  circumstances  of  complication,  render 
the  prognosis  proportionately  more  unfavourable,  212. 
Pubis  ossa  :  See  the  article  Innominata  ossa. 

Radius :  fraSures  of  this  bone  more  frequent  than  those  of  the  cubi- 
tus, 87. 

usual  causes  of  these  fraftures,  ib. 

signs  of  fradture,  ib. 

derangement,  can  only  be  in  the  direftion  of  the  diameter ;  the 
longitudinal,  however,  thought  possible  by  Petit,  88. 

extension  and  counter-extension,  ib. 

caution  in  the  application  of  compresses  and  bandages,  ih. 

method  of  cure,  &c    86  and  83. 

For  luxations  of  this  bone,  see  the  article  Fore-arm. 
Ribs  ;  On  the  Fractures  of:  the  middle  ribs  most  liable  to  this  ac- 
cident, 59. 

the  part  fradfured  is  generally,  near  the  middle  of  the  bone,  60. 

distinftion  of  fradlures  into  inwards  and  outwards,  ib. 

possible  complications,  ib. 

signs  of  these  fractures,  ib, 

derangement  of  the  fraftured  portions:  cannot  take  place  in  the 
direction  of  the  diameter  of  the  bone,  nor  in  that  of  its  axis ; 
but  only  angularly,  ih, 

—experiments  on  this  subjeft,  61. 

treatment  of  simple  fraftures,  either  inwards  or  outwards ;  band- 
ages, ib. 

•—of  cases  where  the  violence  has  been  considerable,^and  the  Iung« 
contused  or  lacerated,  62. 

—of  the  case  of  emphysema,  in  its  different  stages,  62,  63. 

the  cartilages  of  the  ribs ;  the  absurd  praftice  for  raising  "  de- 
pressed ribs"  exposed,  63. 

luxations  of  the  Ribs :  cannot  occur  ;  an  instance  which  has  been 
produced  to  the  contrary,  has  been  mistaken,  and  was  in  reality 
a  simple  frafture  of  the  posterior  extremity,  232. 

this  name  has  been  confounded  with  separations  of  the  dorsal  ver- 
tebrae from  the  head  of  the  rib  by  caries,  233. 

possible  separation  of  the  cartilage  of  the  sixth  true  rib  from  that  of 
the  seventh  by  contraftion  of  the  peftoralis  major ;  depression 
of  the  other  cartilages,  and  of  the  appendix  xyphoides,  59,  6j, 

233- 
Rickets  :  the  enlargement  of  the  ends  of  bones  of  ricketty  persons 
may  be  mistaken  for  exostosis,   178. 
persons  who  have  suffered  by  rickets  in  their  infancy,  may  be  at- 
tacked again  with  this  disease  after  puberty,  189. 


ANALYTICAL   INDEX.  ^47 

(Rickets.     Continued.) 
it  sometimes  aiFeds  the  bones  of  the  foetus,  bat  most  generally 

appears  from  the  sixth  or  seventh  to  the  fourteenth  or  fifteenth 

month  after  birth  ;  difficult  cutting  of  the  teeth  haj  been  consi- 
dered as  a  cause,   189. 
uncertain  whether  it  is  a  primary  affeflion,  or  a  symptom  of  either 

scrofula,  lues,  or  scurvy ;  a  great  connexion  appears  between 

it  and  scrofula,  ib. 
progress  of  the  disease,  90. 
—sometimes  extends  to  produce  caries  in  the  bones,  or  white 

swelling  in  the  joints,  ih. 
the  vertebral  column  particularly  liable  to  this  afFe6lion,  ib. 
its  efFeiils,  when  general,  on  the  different  bones  of  the  body,  191. 
conjeftures,  and  queries,  as  to  the  proximate  cause  of  rickets,  ib% 
appearance  of  the  different  parts,  an  anatomical  inspeflion  after 

death,  ib. 
opinions  as  to  the  cause  of  the  curvature  of  the  bones  ;  opinion  of 

Glisson  ;  attributes  it  to  the  irregular  accumulation  of  the  hu- 
mours, 192. 
—of  Mayow  ;  to  the  tendons  being  dry  and  shortened,  ib. 
—may  be  more  probably  deduced  from  the  effeft  of  the  weight  of 

the  boJy,  and  muscular  contraction,  ib. 
hereditary  in  some  families ;  may  in  some  such  instances  be  traced 

to  a  venereal  taint,  ib. 
influence  ot  dentition  on  the  produftion  or  progress  of  this  disease, 

considered,   193. 
— it  is  singular  that  the  teeth  preserve  their  hardness,  ib. 
prognosis  always  unfavourable,  ib. 
the  crisis  of  puberty,  or  sometimes  the  diseases  to  which  children 

are  subjetl,  arrest  the  progress  of  the  complaint,  ib. 
treatment :  no  medicine  of  efficacy  known  ;    general    treatment 

principally  advantageous,  ib. 
— air,  and  diet ;  exposure  to  the  sun;  materials  of  the  bed,  and 

position  of  the  patient  if  very  young;  chairs;  walking  to  be 

avoided,   194. 
— friftions  useful,  ib. 
— clothing,  ib. 
— qualities  of  nurses  (of  children  at  tke  breast)  j  food  for  weaned 

children  ;  exercise,  ib. 
particular  remedies ;  in  complaints  from  dentition ;  or  in  worms, 

—this  last  complaint  very  common  in  ricketty  patients  ;  its  signs, 
ib. 

means  of  discussing  the  swelling  of  the  njiesenteric  glands ;  tick- 
ling every  day,  to  produce  hearty  laughter,  very  useful,  ib. 

if  proceeding  in  any  degree  from  syphilis  or  scrofula,  the  treat- 
ment for  those  diseases  to  be  recurred  to,  ib. 

it  would  be  a  principal  object,  if  practicable,  to  restore  the  hard- 
ness of  the  bones,  (see  9) ;  madder  has  no  efFedt  in  this  purpose, 
196. 

the  great  end  thus,  is  to  restore  general  health  and  strength,  ih. 

mechanical  means  are  ill  adapted  for  this  disease,  ib. 


348  ANALYTICAL    INDEX. 

Roller ;  its  inefficacy  for  the  purposes  to  which  it  is  applied  in  the 
treatment  of  Iradlures,  26. 

Sacrum  ;  this  bone  not  much  exposed  to  fra^ures,  64. 

treatment,  in  those  accidents,  i6» 

Not  capabit  of  luxation,  230. 

case  of  relaxation  of  the  .;acro-iIiac  synchondrosis  :  See  the  article 
hmominata  oaa  (luxation J. 
Scapula  :  this  boae  not  much  exposed  to  fraftare,  from  its  posi- 
tion, 68. 

— its  different  parts,  however,  vary  in  this  respeft,  ib. 

these  fradures  always  accompanied  with  considerable  contusion,  ib. 

the  longitudinal   hai^lore  less  frequent  than  the  transverse,  and 
causes  very  little  derangement,  ib. 

derangement  in  transverse  iradures,  or  of  the  acromion  and  infe- 
rior angle,  ih. 

— in  fradluresof  the  coracoid  process,  ib. 

signs  of  these  different  fraftures  ;  the  longitudinal,  difficultly  dis- 
tinguished, 69. 

— the  transverse,  more  easily,  ib. 

— the  fradureof  the  inferior  angle,  manifested  by  the  considerable 
derangement,  ib. 

—that  of  the  acromion,  very  easily,  by  a  combination  of  circum- 
stances, ib. 

the  contusion  attending  these  fraflures,  the  most  dangerous  symp- 
tom ;  abscesses,  ib. 

apparatus  for  fixing  the  arm  steady  during  the  cure,  70. 

treatme  t  in  fraftures  of  the  inferior  angle,  ib. 

— uf  the  acromion,  ih. 

time  of  cons.lidaiioa,  71. 

— in  fradures  of  the  acromion  continue  the  bandage  a  little  long- 
er, ib. 

general  remedies ;  as,  blood-letting,  &c.  ib. 

these  fraftures  seldom  dangi  rous ;  instance,  however,  in  which  it 
was  found  necessary  to  trepan,  ib. 
Scultet's  bandage  ;  iis  construction,  application,  and  superior  advan- 
tages, 27. 
Scurvy  ;  its  powerful  influence  in  retarding  the  consolidation  of  frac- 
tures, 22. 

appi:arance  of  the  bones  of  a  scorbutic  person,  when  boiled,    198. 
Signs  oi  fra&ures :  the  sensible  signs  can  alone  give  certainty  of  a 
frafture,    19. 

cautions  in  judging  from  the  relative  shortness  of  the  limb,  20. 

judgments  from  the  change  of  form  and  diredion  of  the  members, 
ib. 

derangement  of  the  fragments  sometimes  perceptible  by  the  fin- 
gers, ib.         ■: 

crepitation  the  most  general  distindlve  symptom,  ih. 

cases  whicii  preclude  any  certainty  of  decision  :  as,  depth  of  fleshy 
parts;  doabie"bones ;  or  inflammatory  swelling,  21. 

— treatment  on  such  occasions,  ih. 

Signs  oi  luxation  :  Seethe  article  Symptoms. 


ANALYTICAL    INDEX.  349 

Simple /ra^ure  defined,   17. 

its  general  treatment,  32. 
Species  oi  frailures  I  distindion  of  five  different,   10. 

1,  as  to  the  bone  affefled,  11. 

—the  broad  bones  not  much  exposed  to  this  accident,  ih. 
— the  short  ones  still  less  so,  and  almost  always  by  muscular  con- 
traction alone;  ib, 
— the  long  bones  very  liable,  iB. 

2,  as  to  the  part  of  the  bones,   \z. 

—in  the  point  of  biseftion,  generally  ;  more  or  less  near,  or  even 

at,  the  extremities  ;  or  in  different  points  at  once,  ih. 
— this  distinction  is  of  real  anri  great  importance,  iB. 

3,  as  to  the  direftion  of  the  fradure,  ih. 

— the  transverse,  the  oblique,  and  the  comminolive  frafture,  ih. 
— the  furth'er  distindion,  of  longitudinal  fradlure,  is  inadmissible, 

4,  as  to  the  relative  situation  of  the  fra£tured  portions,  ih. 

— causes  and  varieties  of  their  derangement  (See  the  article  De- 
rangement), iB. 

5,  distinction  between  simple  and  compound  fra£tures ;  descrip- 
tion of  each,   17. 

Fraftures  are  rarely  accompanied  with  luxation,  ih. 

they  may  be  accompanied  wuh,  or  may  produce,  other  morbid  af- 
fections ;  instances.  iB. 

the  distinction  of  fraCtures  into  complete-  and  incomplete  is  un- 
founded, ih. 

Species  of  luxations :  See  the  article  Differences. 
Spina 'ventosa.     See  the  article  Osteo  sarcoma. 
Spinal  processes,  marrow,  &c.     See  the  article  Vertebrje. 
Splints;  their  comparative  utility  in  the  treatment  of  fractures,  28. 

materials  ;  and  length  and  construction  for  different  parts,  ih. 

their  method  of  aCtion  ;  they  prevent  derangements  in  the  direc- 
tion of  the  diameter,  angularly,  and  (if  properly  applied)  in 
the  circumference,  ih. 

• — derangement  in  the  direction  of  the  axis  in  oblique  fraCtures, 
and  derangement  in  oblique  fraCtures  of  the  clavicle,  almost  im- 
possible to  be  prevented  by  splints  alone,  29. 

importance  of  attention  to  filling  the  different  inequalities  and  de- 
pressions of  the  limb  with  proper  soft  substances ;  tape,  as  an 
external  binding  for  the  whole  apparatus,  preferable  to  strips  of 
linen,  31. 
Spontaneous  luxations  of  the  femur;  called  also  Secondary, 
271. 

two  principal  varieties :  First  variety  ;  from  the  swelling  of  the 
cartilages,  and  the  enlargement  of  the  glands  in  the  interior  of 
the  articulation,  272. 

— this  variety  may  be  produced  by  an  external  cause,  iL. 

— its  ordinary  process,  ih. 

— symptoms,  and  consequences,  ih. 

appearance  on  opening  the  body  after  death,  273. 

Second  variety,  from  caries  of  the  circumference  of  the  acetabu- 
lumi  or  head  of  the  femur:  its  symptoms,  progress,  and  ap- 
pearance on  opening  the  joint,  274. 


3S^  ANALYTICAL    INDEX. 

(Spontaneous  luxations.     Continued.) 

Other  causes  of  both  varieties;  icrolula  especially,  274. 

—objections  0/  those  who  think  an  internal  cause  absolutely  neces- 
sary, ;^. 

Petit's  explanation  of  the  manner  in  which  these  luxations-  take 
place,  ilf. 

—futility  of  this  explanation,  275. 

Prognosis;  diiFerent  according  to  the  age  and  constitution  of  the 
patient,  the  species  of  luxation,  its  continuance,  and  cause,  iB, 

Treatment:  the  principal  objeft  is  to  prevent  the  spontaneous  lux- 
ation ;  method,  i6. 

— if  a  constitutional  taint  is  sospefted,  the  remedies  must  be  di- 
refted  to  this,  276.    . 

— good  cfFefts  of  a  large  blister  on  the  hip,  iB. 

when  these  means  fail,  the  progress  of  the  disease  shoifld  be  arrest- 
"      ed  by  favouring  the  attachment  of  the  head  of  the  femur  to  the 
bones  of  the  pelvis ;  treatment,  ii, 

—if,  nevertheless,  abscesses  are  formed,  their  opening  should  be 
retarded,  277. 

The  luxation  downwards  and  inwards  less  frequent  than  that  up- 
wards and  outwards  ;  instance,  however,  of  the  former,  i6. 

its  treatment,  and  consequences,  278. 
Sprains;  definition  of  this  term,   199. 

different  sorts  of  articulations  more  or  less  liable  to  this  accident, 

a. 

nature  of  the  affeflion  explained,  ti>. 

—appearances  which  immediately  follow  it,  200. 

time  of  re-establishment  in  cases  of  slight,  or  of  more  considerable, 
injury,  ii. 

diagnosis,  ii. 

prognosis,  unfavourable  according  to  circumstances,  201. 

treatment,  varies  according  to  the  continuance  of  the  afFeftion  ;  if 
adopted  immediately,  apply  cold  water  or  powdered  ice  for  a 
considerable  length  of  time,  except  in  certain  cases,  ii. 

absurd  pradlice  of  ignorant  bone-setters,  202. 

the  repellent  mode  cannot  succeed  if  an  interval  of  twflve  hours 
has  elapsed  :  treatment  in  ^this  case  ;  bleeding,  emollient  cata* 
plasms,  resolvents,  solvents,  ii. 

— long  inadlivity,  and  posture,  of  the  limb  ;  application  of  a  rol- 
ler, ii. 

serious  ultimate  consequences  of  bad  treatment  in  any  respeft,  203. 

dangerous  nature  of  this  afFeftion,  £0  trifling  in  the  eyes  of  the  vul- 
gar, a. 

treatment  of  the  bad  symptoms  succeeding  to  sprains,  i^. 

Sprain  of  the  foot,  how  distinguished  from   luxation  backwards., 
287. 
Stays,  a  frequent  cause  of  deformity  in  children,  or  of  dangerous 
disease,  315. 

cases,  however,  in  which  stays  of  a  certain  construdlion  may  serve 
to  corretll  disproportions,  316,   317. 
Sternum  :  this  bone  not  much  liable  to  fraftures ;  different  ways, 
however,  in  which  they  may  happen,  57. 


ANALYTICAL    INDEX.  35 1 

(Sternum.     Continued.) 

1,  by  extension  operating  on  both  cjttremi tics  of  the  bone;  in- 
stance (produced  by  the  violent  adlion  of  muscles),  57. 

2,  by  the  immediate  aftion  of  an  external  cause;  its  attendant 
circumstances,  58. 

effusions  of  blood  attending  solutions  of  continuity,  however  abun- 
dant, seldom  dangerous,  ib. 

simple  fradlure ;  its  signs,  and  treatment,  ib. 

complicated  fiadure  ;  treatment,  ib. 

— trepanning  seldom  necessary  j  very  great  care  in  performing 
this  operation,  59. 

affcftions  of  the  appendix  xyphoides,  ib. 
Sv;addli7ig.clothes,  a  very  produdive  cause  of  deformity,  315. 
Symptoms  of  luxation :  pain,  and  inability  of  moving  the  limb,  equi- 
vocal symptoms,  but  not  to  be  disregarded,  209. 

others,  more  decisive:  i,  an  elongation,  or  shortening,  of  the 
limb ;  both  instanced  in  dislocations  of  the  head  of  the  femur, 
210. 

— 2,  change  in  the  diredlion  of  the  bone;  most  easily  distingaisb- 
ed  in  recent  cases,  ib. 
■  change  in  the  shape  of  the  limb,  ib. 

— 3,  the  imposbibility  of  performing  certain  motions,  211. 

by  these  different  circumstances  a  clear  diagnosis  is  established; 
frequency,  and  disgrace,  of  an  error  in  this  point,  ib. 

Sytaptoms  of  fracture:   See  the  article  iS/g^«j. 
Synovia :  its  qualities  have,  in  some  cases,  been  considerably  changed 
by  the  contaft  of  air,  so  as  to  produce  inflammation  which  ter- 
minated in  a  caries  of  the  ends  of  the  bones,  292. 

See  also  the  Chapter  on  Dropsy  of  the  Articulations,  288. 

Tarsus;  On  fracture  of  the  bones  of:  of  the  os  Calcis.    See  that 

article, 
the  other  bones  susceptible  only  of  comminutive  frafture,  154. 
treatment,  the  same  as  tho^e  of  the  Hand,  93.   154. 
For  luxations  of  these  bones,  see  the  article  Foot. 
Thigh.     This  member  exposed  to  a  great  variety  oi  fra^ures,  96. 
all  the  species  of  derangement  may  occur ;  the  longitudinal  the 

most  frequent;  a£tioa  of  the  numerous  muscles  in  producing 

these,  96. 
—the  muscular  aSion  in  fraftures  above  the  condyles ;  and,  when 

the  great  trochanter  is  detached  from  the  rest  of  the  bone,  ib. 
-~<4he  angular  derangement  occasioned  by  the  inclination  of  the 

foot,  97. 
signs  of  fraflures ;  these  accidents  more  dangerous  in  this  than  in 

any  other  limb,  and  require  more  unremitting  care  and  atten- 
tion, ib. 
•ome  diredions  in  this  last  point :  dimensions  and  construftion  of 

the  bed  ;  and  disposition  of  the  body  of  the  patient,  98. 
—apparatus:  bandages;  compresses;  splints,  and  their  different 

lengths  ;  bags  of  chaff,  to  fill  the  intervals  of  the  limb  ;  strings, 

or  ribbands,  98,  99. 
—error  of  some  praftitioners  in  th«  application  of  bandages,  98. 


35'^  ANALYTICAL    INDEX* 

{Tkich:  fraaures  oi.     Continued.) 
— earliest  trentment :  arrangement  of  the  apparatus,  on  the  bed  ; 

disposition  and  removal  of  the  patient;  setting,  99. 
■  application  of  the  apparatus,  ib. 
— subsequent  treatment:  bleeding,  and  regimen;   periodical  re- 
moval of  the  apparatus ;  time  lor  final  removal  of  the  bandage, 

^g,  100. 
in  cases  of  oblique  frafture,  continued  extension  to  be  employed, 

100. 
treatment  of  very  young  children,  ib. 
in  frafturcs  near  the  condyles,  the  hollow  of  the  ham  must  be 

stuffed  with  lint,  ib. 
compress  and  bandage  in  separation  of  the  great  trochanter  from 

the  rest  of  the  bone,   loi. 
time  of  consolidation,  ib. 
—in  very  tedious  cases,  a  stiffness  in  the  articulation  of  the  knee 

to  be  apprehended,  ib. 
compound  fraftures,  ib. 
See  also  the  article  Neck  of  the  femur. 

For  luxations  of  the  Thigh,  See  the  article  Femur. 
Tibia :  the  fra£iures  of  this  bone  are  almost  always  transverse,  and 
therefore  not  very  dangerous,   147. 
if  near  the  inferior  extremity,  no  considerable  derangement  takes 

place,  ih. 
this  last  circumstance  occasions  the  diagnosis  to  be  often  very  dif- 
ficult, ih. 
usual  means  of  ascertaining  it,  ii. 
treatment;  setting,   148. 

time  of  consolidation  ;  the  articulations  are  not  injured,  ib. 
For  fractures  o^  both  bones  of  the  leg,  see  the  article  Leg. 
luxations  of  the  Tibia  at  its  articulations  with  the  condyles  of  the 

femur;  may  occur  in  four  different  diredtions,  282. 
— I,  backwards;  this  always  incomplete,  and  as  often  secondary 

as  primary,  ib. 
—2,  forwards  ;  more  rare  than  the  preceding,  ib. 
3 1  and  4,  laterally;  inwards  or  outwards:   these  the  most  fre- 
quent, and  always  incomplete,  ib. 
symptoms  of  the  backward,  and  of  the  opposite,  luxation,  ib. 
~of  the  lateral  luxations,  283. 

in  every  case  of  luxation  the  redudlion  is  easy  ;  method  of  prevent- 
ing a  return,  from  the  too  great  laceration  of  the  parts,  ib. 
the  principal  objeft  of  Treatment  is  the  laceration  of  the  soft  parts : 
inflammation  ;  abscesses ;  gangrere  :  perhaps  a  complete  luxa- 
tion of  the  tibia  from  the  femur  may  be  considered  as  a  case  re- 
quiring immediate  amputation,  283 
Instance  of  the  carious  extremity  of  this  bone  and  of  the  femur  cut 
off  in  the  case  of  white  swelling,  3Q9. 
Toes.     See  the  article  Phalanges. 
Vransverse  fraSita-e  dthnedi,    12. 

less  dangerous  than  oblique,   21. 
'rreat?ne?u   (general)   ui  fratiures :   first  indication   is  to  confine.  Or 
restore  the  fragments  to  their  natural  situation,  22. 


ANALYTICAL    INDEX.  353 

iXreatment  of  fra3ures.     Continued.) 

— methods  of  setting  a  fraftuied  bone:  extension  and  counter-. 
extension,    not  always  necessary     (See   the  article  Extetujon) 

^3'  24. 

second  indication:  to  maintain  the  portions  in  exa£l  conta£l,  and 

_,    motionless,  during  the  consolidation  of  the  frafture,  24. 
° — situation^of  the  limb:  a  horizontal  plane;  its  adaptation,  and 
materials,  25. 

•^rpositicn  o(  the  limb;  demi-flexion,  or  straightness:  advantages 
and  disadvantages  of  each  ;  thft.-Jatter  preferable,  ib. 

— necessity  of  peitedt  repose  to  the  limb,  ib. 

—bandages  (See  that  article),  ib. 

— faux-fanons,  splints  (See  that  article),  and  apparatus  for  efFeil- 
ing  perpetual  extension  (See  the  article  Extension),  27  to  31. 

third  indication  ;  to  prevent  any  succeeding  complication,  3 1. 
■   ■  solutions  proper  to  be  applied  to  the  parts,   32. 
regimen,  ib. 

•^or,  to  remedy  the  different  cases  of  COTiplication  when  they  have 
taken  place,  ib. 

——as,   I,  the  case  of  fradture  accompanied  with  luxation,  ih. 

question  whether  the  dislocated  fragment  should  be  first  re- 
placed, or  not,  till  the  consolidation  of  the  fradure  is  efFedled, 

33- 
2,  when  the  soft  parts  are  violently  contused,  without  external 

wound,  ib. 

3,  when  a  vessel  of  a  certain  magnitude  is  opened  by  a  frac- 
ture ;  instance,  ib. 

4,  wounds  occasioned  by  the  penetration  of  the  point  of  on« 

of  the  fragments  through  the  integuments ;  instance,  34. 

I  ■  wounds  occasioned  by  the  same  causes  as  the  frafturc,  as  in 
jcomminutive  fradtures :  treatment ;  the  various  circumstances 
and  cases  in  which  amputation  is  necessary,  34  to  36. 

Treatment  of  luxations  :  principal  indications  to  be  fulfilled  in  this 
view;   i.  To  reduce  the  luxated  bone,  212. 

this  is  efFefted  by  means  of  extension,  counter-extension,  and  co- 
aptation, ib. 

— Extension:  part  on  which  the  extending  force  should  be  ap- 
plied ;  advantage  oi  th«  modern  pradice  over  the  ancient  in 
this  respeft,  213. 

— — objeftion  to  the  former,  ill-founded,  ib. 

— means  of  effefting  extension  ;  the  hands  of  intelligent  and  strong 
assistants  preferable  to  any  mechanical  means,  ib. 

—degree  of  force  to  be  used  ;  to  be  varied  according  to  circum- 
stances;  mechanical  means  never  to  be  resorted  to,  214. 

— diredtion  in  which  it  is  to  be  applied  :  should  be  at  first  that 
which  the  luxated  bone  has  taken  ;  illustration  of  the  necessity 
of  this  pradtice,  ib. 

the  bone  to  be  gradually  brought  back  to  Its  natural  position 
ib. 

— Counter-extension:  part  on  which  the  force- for  this  pprpoic 
should  be  applied,  215. 

4S 


* 

354  '   ANALYTICAL    INDEX. 

{^Treatment  of  luxaliom.     Continued.) 

—means  of  efFeiting  counter-extension  ;  the  hands  of  the  assistants, 
by  the  use  of  fillets,  ih. 

— diredion  in  which  this  force  is  to  be  made;  always  perpendicu- 
lar tp  the  surface  of  the  luxated  joint,  zB.  .*s,^- 

•—the  most  intelligent  of  the  assistants  should  be  employed  in  ma- 
king extension,  ih.  ^ 

—Coaptation  ;  easily  performed  when  the  extensiotf^s  sufficient, 

'^  .  .  .  .  ^ 

when  the  operations  fail  throjngh  insufliciency  of  the  means  em- 
ployed, these  may  be  aided  either  by  increasing  (he  number  of 
assistants,  or  diminishing  the  muscular  force  of  the  patient,  216. 

—different  ways  of  effcdling  the  latter  purpose  ;  by  change  of 
posture,  ib. 

hy  repeated  bleeding,  the  warm  feath,  and  very  low  diet,  ih. 
■  a  state  of  intoxication  favourable   to  this  end  ;  it   has  ever 
been  advised  tu  intoxicate  the  patient  in  that  view,  ib. 

by  fatiguing  with  c6ntinual   aftion   the  musclts  surrounding 
the  luxated  bone;   instances  of  this  praftice,  ih. 

luxations  that  have,  through  mistake,  continued  several  days  be- 
fore application,  difficult  or  impossible  to  be  reduced  :  treat- 
ment ;  warm  baths  and  pumping,  exercise,  and  regular  mo- 
tion of  the  luxated  bone,  217.  ^ 

—if  a  certain  period  has  elapsed,  and  anchylosis  has  geni^ally 
taken  place,  ib. 

signs  of  the  luxation  being  reduced,  ib. 

the  praftitioner  should  never  be  discouraged  and  despair  in  cases 
(if  recent  luxation;  perhaps  none  such  are  absolutely  irreduci- 
ble, 218. 

2,  Tu  preserve  the  reduced  bone  in  its  place:  perfeft  rest  is  the 
only  requisite  ;^mployiiient  of  bandages  for  this  purpose,  218. 

luxation  arising  from  any  internal  cause,  ib. 

3,  To^prevent  or  remove  the  symptoms  with  which  the  luxations 
may  be  complicated  ;  enumeration  of  these  causes  of  complica- 
tion, including  lra£lure  (See  17,  32);  treatment  in  each  case, 
218  .  •  f 

Consequences  of  luxations  not  reduce^,  219. 

Vertebrje:  these  bones  not  much  liable  to yra-ffKr^;  when  it  dqgs 

occur,  the  mere   fradure  is  less  dangerous  than  the  consequent 

lesion  of  the  spinal  marrow,   54. 
— manner  in  which  (in  such  a  case)  the  efieft  on  that  substance  is 

produced,  ih. 
the  diagnosis  of  these  fraftures  is  difficult  to  establish  :  some  rules  j 

instance,   54,   55. 
the  common,  n  or  violent  distension  of  the  spine  may  produce  the 

same  cff^dts  as  a  fracture  of  this  sort ;  instance,  55. 
process  of  the  fatal  termination  of  these  accidents,  55,  56. 
attempts  at  setting  this  fradure  are  useless ;  general  treatment  the 

only  resource,  54. 
—treatment  in  flatulent  distension  of  the  abdomen,  &c.  ib. 
trepanning  has  been  injudiciously  recommended,  57. 


♦     ^  ANALYTICAL    INDEX.  ^SS 

(Vertsbr^.    XJonlinued.) 

fradure  of  the  vertebra;,  or  afFeflion  of  the  spinal  marrow,  In.  the 

neck,  produces  speedy  or  instantaneous  death,  i^. 
—lesion  ot  the  fourth  and  Hith  cervical  pairot  nerves,  ii>. 

Of  luxations  of  the  Vertebrae;  these  dislocations  in  the  dorsal  and 
lumbar  part  of  the  column  are  impossible;  but  in  the  cervical 
vertebjs  they  may  occur,  225. 

—instance,  ot  a  luxation  lower  down  than  the  second  vertebra,  ii. 

Luxations  of  the  Head  from  the  first  Vertebra,   226. 

cannot  be  occasioned  by  an  external  cause  ;  such  an  occurrence 
would  destroy  the  individual,  i5. 

may  take  place  gradually  and  insensibly,  iS. 

Luxations  of  the  First  Cervical  Vertebra  from  the  Second;  ren- 
dered easy  by  the  conformation  of  ttie  parts,  ii. 

process  of  the  luxation,  /^. 

circumstances  wliich  sometimes  render  it  fatal,  by  a  compression 
of  the  spinal  marrow,   227. 

different  manner  of  dying,  of  the  criminals  hanged  at  Lyons  and 
those  at  Paris ;  occasioned  by  a  trivial  custom  of  the  executioner 
of  the  former  place,  i5. 

remarkable  case  of  fatal  lux^ition,  from  the  motion  occasioned  by 
the  person  himself;  a  caution  against  a  dangeruus  manner  of 
playing  with  children,  i3, 

the  relaxation  of  the  ligaments  of  the  tooth-like  process  may  fa- 
vour this  luxation  ;  in  luxations  of  the  neck  which  are  not  fatal, 
the  dislocation  takes  piace  lower  down  than  the  second  vertebra, 
228. 

—instances,  ii. 

— symptoms  of  these  cases,  229. 

in  luxations  not  indicating  a  compression  of  the  spinal  marrow, 
their  reduflicn  should  not  be  attempted  ;  method  of  proceeding, 
however,  when  the  patient  insists  upon  it,  il>. 

White  sv/ellings  of  the  joints  ;  defined,  301. 

varieties:  i,  the  rheumatic ;  its  symptoms,  progress,  and  conse- 
quences, 301,  302. 

occurs  in  various  articulations,  but  principally  in  i&e  knee,  302. 

—appearance  on  dissedion,  ii?. 

— 2,  from  a  scrofulous  taint:  the  various  symptoms,  progress, 
consequences,  and  appearance  on  dissedtion,  i6. 

numerous  farms  of  this  disease  in  different  patients,  236. 

seldom  produced  by  an  external  cause  ;  sometimes  occurs  without 
any  apparent  cause ;  in  scrofulous  persons  it  may  follow  external 
violence,  303. 

theenlargementof  the  ends  of  the  phalanges,  (183,  184,)  belongs 
to  this  class  of  diseases,   303. 

the  prognosis  always  unfavourable;  less  so  in  children  under  the 
age  ot  puberty.  iB.  ' 

a  multiplicity  ot  remedies  have  been  proposed  for  this  disease,  ii. 

treatment,  304. 

—warm  or  mineral  water,  &c.   kind  of  animal  bath,  305. 


35^  ANALYTICAL    INDEX.  *     § 

(White  swellings  of  the  joints.     Continued.) 

—very  violent  means,  as  the  adlual  cautery  and  burning  with 
nioxa,   dangerous,  305. 

—after-treatment,  ib. 

treatment  in  scrofulous  cases,  305. 

daring  pradice  of  some  empirics,  in  employing  acrid  and  stimu- 
lating applications  J  instance  ot  entire  rectory  in  this  treat- 
ment, 305. 

treatment  in  cases  of  numerous  abscesses,  and  considerable  col- 
ledions  of  pus,   306, 

amputation,  when  necessary ;  not  to  be  too  hastily  resorted  t0)  ii. 

— considerations  determining  on  the  propriety  of  this  operaltion/ 

—not  to  be  performed  but  in  cases  where  only  one  joint  is  afFeft- 
ed,  ib. 

pra«5lice  proposed  instead  of  amputation;  of  cutting  ofF  or  extir- 
pating the  carious  extremities  of  the  bones,  when  the  state  of  ihe 
soft  parts  admits  of  it,  307. 

— cases  in  which  alone  this  operation  is  practicable,  308. 

— method  of  performing  it ;  on  the  head  of  the  humerus,  ib, 

——instances,  309. 

—proposed  by  Paric  to  be  extended  to  the  articulations  of  the  knee 
and  elbow:  but  this  is  more  hazardous :  instance  of  his  accom- 
plishing it  on  the  former,  ib. 

—its  danger,  and  small  comparative  recommendations,   310. 

— mei!iod  in  performing  it  on  the  elbow,  ib. 
Wounds,   and   Denudation,  of  the  Bones;  these  two  cases 
must  be  carefully  distinguished,   154. 

if  the  bone  is  merely  stript,  replace  the  parts  immediately  and  the 
periosteum  will  speedily  reunite,  ib. 

if  the  external  lamina;  are  contused,  or  its  surface  is  long  exposed 
to  the  air  or  to  the  fridlion  of  bandages,  exfoliation  takes  place, 
and  the  integuments  must  not  be  prematurely  closed,  ib. 

treatment  in  each  case  :   i,  in  simple  denudation,   155. 

—  2,  in  cases  of  exfoliation  :  nature  of  this  process,  ib. 

— method  employed  to  expedite  the  exfuliation  ;  oily  relaxing  ap- 
plications,  156. 
■perforation  for  this  purpose,  injurious,  ib. 

—incision  sometimes  necessary,  to  separate  the  detached  portion, 
ib. 

3,  in  cases  of  complete  division  of  the  bone,  ib: 
—the  wound  must  be  healed  from  the  bottom,   157. 

— if  the  bone  is  cut  quite  through,  treatment  and  apparatus  to  be 
applied  as  in  a  case  of  fraflurr,  ib. 

and  the  time  of  reunion,  and  manner  of  consolidation,  the 

•  same,  157. 

Wounds  of  the  Articulations  ;  held  to  be  dangerous,  by  all 
the  ancient  and  almost  all  the  modern  writers,  297. 

instances,  on  the  contrary,  of  their  healing  with  the  greatest  fa- 
cility ;  I,  a  wound  in  the  elbow  by  a  piece  of  glass  which  pe- 
r.etrated  into  the  cavity  of  the  joint,  ib. 


ANALYTICAL    INDEX.  357 

(Wounds,  and  Denudation,  of  the  Bones.     Continued.) 

— 2,  a  wound  in  the  same  joint  by  a  small  sword,  in  which  the 
capsule  of  the  joint  was  opened,  298. 

instances  that  wounds  by  cutting  instruments  are  not  very  danger- 
ous, even  notwithstanding  the  admission  of  air  ;  1,  the  poste- 
rior part  of  the  articulation  of  the  wrist  entirely  opened,  ih. 

—2,  the  same  articulation  opened,  by  a  piece  of  a  vessel  of  delf 
ware,  ib. 

—3,  the  same  articulation  opened  for  about  one  third  of  Its  cir- 
cumference, ib. 
ji  —The  facility  with  which  Incisions  are  made  to  extraft  foreigti 
bodies,  also  a  proof  of  this,  ib. 

the  occurrence  of  inflammation  in  cases  of  the  latter  description, 
terminating  in  gangrene  or  ultimately  in  caries,  must  arise 
from  long-continued  and  powerful  adion  of  the  air,   299. 

•^the  imprudent  application  of  dressings  to  the  surfaces  of  the 
joint  still  more  dangerous:  instance,  a  sabre-wound  on  the  ex- 
ternal side  of  the  wrist  filled  with  charpie,  ib, 

—the  danger  equally  great  when  the  wound  suppurates:  instances; 
— 1,  a  sabre-wound  dividing  the  patella,  ib. 

2,  a    sabre-wound    on   the  anterior  part  of  the  point  of  the 

shoulder,  299. 

——.3,  a  sabre-wound  in  the  inferior  part  of  the  arm,  300. 

conclusion;  the  prognosis  of  wounds  in  the  articulations,  in  what 
circumstances  favourable,  ib. 

indications  of  cure,  ib. 
Wrist.     See  the  article  Carpus. 

Zygomatic  arch:  case  of  its  frafture  (as,  by  the  wheel  of  a  carriage)  ; 
treatmerit,  45. 


4  # 


NOTES. 


NOTE  I. 

«<  THE  apparatus  for  perpetual  extension  should  not  be  applied 
before  the  irritation  and  spasm  of  the  muscles  are  completely 
removed  i"    Page  29. 

There  are  certainly  many  cases  in  which  this  rule  will  hold 
good.  But  the  spasmodic  adlion  of  the  muscles  has  frequently 
been  removed  by  applying  the  apparatus  for  permanent  exten- 
sion. In  a  case  of  oblique  compound  fra^lure  of  both  bones  of 
the  leg,  which  occurred  last  winter  in  the  Pennsylvania  Hos- 
pital, under  the  care  of  Dr.  Physick  these  disagreeable  symp- 
toms were  entirely  done  away  by  the  application  of  the  exten- 
ding splints  invented  by  Dr.  Hutchinson.  A  few  hours  after 
being  applied,  the  splints  by  accident  became  displaced,  in  con- 
sequence of  which  the  pain  and  spasmodic  action  returned. 
The  patient  was  immediately  relieved  by  again  adjusting  the 
splints. 


,  NOTE  II. 

"A  man  aged  36  had  his  arm  fra£lured,  and  nothing  was  done 
to  adjust  the  fractured  bone.  This  arm  had  been  so  long  use- 
less to  the  patient,  that  he  was  determined  to  undergo  any  trial 
for  effecting  the  cure,  &c."    Page  43. 

In  a  case  very  similar  to  this.  Dr.  Physick  pursued  a  different 
and  more  successful  mode  of  treatment.     Instead  of  sawing  off 


,360  NOTES. 

the  ends  of  the  frafVured  portions  of  bone,  a  seton  was  passed 
between  them.  The  wound  went  through  all  the  different 
stages  which  arc  necessary  to  effe£t  re-union  in  compound  frac- 
tures. Inflammation  and  suppuration  were  succeeded  by  gra- 
nulations, which,  by  ossifying,  produced  a  complete  bony  union 
at  the  end  of  thirteen  weeks  from  the  day  on  which  the  ope- 
ration was  performed.  The  seton  was  removed  at  the  end  of 
the  twelfth  week. 

See  a  Paper  by  Dr.  Physick,  in  the  New-York  Medical  Re- 
pository, Hex.  2.  vol.  1.  p.  122. 


NOTE  III. 
"If  in  a  fra£lure  of  the  superior  maxillafy  bone,  &c."  Page  4^5. 

In  the  third  volume  of  the  London  Medical  Fa£ts  and  Ob- 
servations a  case  is  related,  in  which  the  ligatures  as  recom- 
mended by  Le  Dran  were  of  very  little  use  in  retaining  the 
fra£lured  portions  in  their  natural  situation.  This  indication, 
however,  was  completely  fulfilled,  by  placing  a  piece  of  sponge 
between  the  teeth  of  the  upper  and  lower  jaw.  The  gradual 
expansion  of  the  sponge  reduced  the  frafture  in  about  thirty- 
six  hours.  The  sponge  was  changed  daily  for  about  a  month. 
Its  use  was  then  discontinued  entirely,  and  the  patient  reco- 
vered soon  after  without  any  deformity,  except  the  loss  of  the 
fore  teeth. 


NOTE  IV. 

"  Paralysis  induced  by  fradlures  of  the  cervical  vertebrx.** 
Pages  55y  oSj  57. 

Persons  labouring  under  paralytic  afFeftions  are  very  liable 
to  gangrene,  from  long  continued  pressure.  In  other  lingering 
diseases,  the  pain  which  the  compression  of  any  part  occasions, 
generally  compels  the  patient  to  change  his  position.  In  palsy 
however,  this  salutary  warning  is  never  given.  But,  how  easily 
may  we  guard  against  the  evils  that  would  result  from  this  sus- 
pension of  some  of  the  operations  of  nature,  by  substituting 
those  of  art.  All  that  is  necessary  is  to  change  frequently  the 
position  of  the  patient. 


NOTES.  361 

l"'he  etfeft  of  pressure  from  the  weight  of  the  body,  is  not 
the  only  evil  that  we  have  to  contend  with  in  fra£lures  of  the 
cervical  vertebrae. 

Muscular  aftion  is  frequently  the  cause  of  the  greater  part 
of  the  dreadful  consequences  which  almost  invariably  succeed 
fra^lures  of  these  bones.  The  circumstance  of  their  being  so 
very  moveable  upon  each  other,  will  perhaps,  in  some  measure, 
explain  the  facSi:,  that  injuries  done  to  them  are  so  frequently 
fatal.  If  the  whole  spinal  canal  were  a  complete  and  immove- 
able bony  tube,  fradlures  might  sometimes  take  place  in  the 
spine,  as  they  do  in  the  cranium,  without  depression. 

But  as  this  canal  is  composed  of  a  number  of  distin£l  bones, 
each  of  which  has  strong  muscles  inserted  into  different  parts 
of  it,  we  cannot  easily  conceive,  that  a  fraclure  of  any  of  the 
true  vertebra  can  ever  occur,  without  being  accompanied  with 
a  compression  of  the  spinal  marrow.  In  what  manner  shall  we 
endeavour  to  remove  this  compression  ?  Perhaps  the  best  an- 
swer that  we  can  give  to  this  question  will  be  to  relate  the  fol- 
lowing case: 

Peter  Colberry  was  admitted  into  the  Pennsylvania  Hospital 
on  the  15th  November,  ISOi.  About  half  an  hour  previously 
to  his  admission,  he  fell  from  a  height  of  ten  feet,  upon  his 
head  and  back. 

The  upper  and  lower  extremities  were  paralytic,  the  head 
was  turned  a  little  to  the  left  side,  and  the  neck  was  somewhat 
contrafted.  The  patient  was  unable  to  rotate  the  head  upon 
the  second  vertebra,  but  could  easily  turn  it  in  every  direftion 
by  moving  the  whole  neck.  Upon  making  some  extension  a 
crepitation  was  felt  in  the  cervical  vertebrx.  His  pulse  at  this 
time  was  so  much  depressed  as  to  be  scarcely  perceptible.  On 
the  morning  of  the  16th  it  became  somewhat  fuller,  and  the 
pain  in  the  neck  increased  considerably.  This  symptom  how- 
ever, was  by  no  means  so  distressing,  as  a  difficulty  of  breathing 
which  came  on  about  this  time.  The  man  was  unable  to  cough, 
and  was  apparently  almost  suffocated  by  a  collection  of  mucus 
in  the  trachea.  Upon  turning  him  so  as  to  have  the  face 
downward,  with  a  view  of  examining  the  vertebrcc,  so  great  a 
compressioa  v/as  made  upon  the  abdominal  viscera,  and  dia- 
phragm, as  almost  to  put  a  stop  to  respiration. 

Dr.  Physick  ordered  an  apparatus  to  be  applied,  by  which  the 
neek  was  kept  extended.  The  feet  of  the  patient  were  secured 
to  the  lower,  and  his  head  to  the  upper  part  of  the  bedstead.  See 
Plate  1.  fig.  1. 

46 


302  NOTES. 

Two  hours  after  this  dressing  had  been  appUed,  the  man  reco- 
vered in  some  measure,  the  use  of  his  arms.  The  difficuhy  of 
respiration  however,  continued,  and  at  5  o'clock  on  the  morning 
of  the  17th  he  died. 

The  muscles  were  not  contrafted,  and  the  blood  had  not  co- 
agulated. The  spinous  process  of  the  fifth,  and  the  body  of  the 
sixth  cervical  vertebra,  were  fractured,  and  pressed  upon  the 
spinal  marrow.  A  considerable  quantity  of  dark  coloured  coa- 
gulated blood  was  found  between  the  spinal  marrow  and  the 
membrane,  which  lines  the  cavity  of  the  spine. 

The  immediate  cause  of  this  man's  death  was,  in  all  probabi- 
lity, a  coUedtion  of  mucus  in  the  trachea,  which  a  paralysis  of 
the  abdominal  mtiscles,  rendered  him  unable  to  discharge. 

Notwithstanding  the  fatal  termination  of  this  case,  the  cir- 
cumstrmce  of  the  patient's  being  able  to  move  his  arms  soon 
after  the  application  of  the  apparatus,  affords  some  ground  for 
the  belief,  that  in  fraftures  of  the  cervical  vertebrae,  permanent 
extension  of  thfe  neck  may  sometimes  retain  the  fragments  in 
their  natural  situation,  and  prevent  them  from  pressing  upon  the 
spinal  marrow. 

A  delineation  of  this  apparatus  is  given  in  Plate  1.  fig.  1. 

A.  A.    Bandages  passed  round  the  ancles. 

B.  Another  bandage  tied  to  the  former,  and  secured  to  the 
upright  piece  C.  at  the  foot  of  the  bed.  This  servos  to  make 
the  counter  extension. 

For  the  extension  a  leather  strap  D.  is  passed  round  the  head, 
and  buckled  on  the  vertex.  E.  another  strap  sewed  to  the 
former,  and  carried  under  the  occiput. 

F.  F.  A  bandage  which  ties  the  strap  to  the  nut  G.  of  the 
screw  2. 

Fig.  2.  A  m.ale  and  female  screw,  invented  and  first  used  by 
Dr.  James  Stuart,  in  fraiStures  of  the  feg  and  thigh. 

The  use  of  this  dressing  is  attended  with  several  inconveni- 
encies.  It  is  frequently  necessary  to  move  the  body  of  the  pa- 
tient— whenever  this  is  done  the  extension  will  be  rendered 
more  or  less  oblique.  It  requires  too  much  force,  as  almost  all 
the  ligaments  and  muscles  of  the  whole  body  must  be  elongated. 

I  have  proposed  an  apparatus,  Plate  1.  fig.  3,  4,  5,  which  may 
perhaps  obviate  some  of  these  objections. 

Fig.  3.  Two  pieces  of  board  about  two  feet  in  length,  half 
an  inch  thick,  and  eight  inches  wide.  The  lower  end  should 
be  excavated  and  covered  with  bolsters  to  receive  the  shoulders. 
Two  mortises  in  the  upper  ends  receive  the  cross  pieces  fig.  4. 


s 


NOTES.  2^2 

Fig.  5.  is  a  representation  of  the  apparatus,  when  applied- 
Bandages,  or  leather  straps,  are  passed  round  the  head  as  in  fig. 
1.  carried  through  a  hole  in  the  first  cross  piece,  and  tied  to 
the  screw. 

If  the  screw  should  not  be  at  hand,  a  common  tourniquet 
will  answer  the  same  purpose. 

In  fractures  of  the  dorsal  vertebrae,  this  dressing  would  be  of 
no  avail.  For  if  a  fradlure  occur  in  any  part  of  the  spine  below 
the  last  cervical  vertebra,  it  is  evident,  that  the  counter  exten- 
sion must  be  made  against  some  point  below  the  first  rib.  If, 
instead  of  making  the  counter  extension,  as  proposed  by  Dr. 
Physick,  the  ossa  ilia  should  be  chosen  for  that  purpose,  nothing 
is  gained  •,  as  it  is  frequently  necessary  to  raise  the  pelvis,  and  irj 
doing  this,  an  angle  v/ould  be  formed  at  the  fradlured  part. 


NOTE  V. 

"Apparatus  forfraftures  of  the  clavicle."     Page  77. 

This  apparatus  is  simple  in  its  construftion,  and  can  be  very 
easily  applied.  It  fulfils  every  indication  which  should  be  at»- 
tended  to  in  the  treatment  of  these  fradlures,  except  that  of 
raising  the  arm.  With  a  view  of  supplying  this  desideratum, 
and  of  rendering  the  dressing  for  a  fradtured  clavicle  still  more 
simple,  I  have  proposed  a  modification  of  Boyer's  apparatus- 

As  the  construdtion  and  manner  of  applying  it  will  be  readily 
understood  by  taking  a  view  of  Plate  2.  we  need  not  enter  into 
a  lengthy  description  of  it. 

Fig.  1.  a  cushion,  to  be  placed  under  the  arra.  Fig.  2.  a 
roller,  about  twelve  inches  in  width,  and  four  feet  long,  confines 
the  cushion  to  the  body.  This  part  of  the  dressing  has  holes 
at  each  extremity,  through  which  tapes  are  passed,  and  three 
loops  L.  L.  L.  Before  the  tapes  are  tied,  the  fore  arm  is  to  be 
carried  through  the  middle  loop,  as  at  L.  fig.  5. 

Thus  the  first  bandage  serves  the  double  purpose  of  confining 
the  cushion  to  the  body,  and  of  supporting  the  fore  arm.  To 
prevent  the  cushion  from  slipping  downward,  it  may  either  be 
sewed  to  the  roller  2,  or  supported  by  straps  passed  over  the 
opposite  shoulder. 

Fig.  3.  another  piece  of  linen,  six  inches  wide,  and  about 
^ye  feet  in  length.     It  is  passed  over  the  arm,  and  through  the 


364  NOTES. 

loops  L.  L.  L.  and  tied  behind  with  tapes.  The  straps  A.  B. 
fig.  5.  which  support  the  whole  dressing,  may  be  either  passed 
through  loops,  or  sewed  to  the  first  bandage,  before  and  behind. 

Fig.  4,  a  bandage  four  inches  wide,  and  a  yard  long,  sypports 
the  elbow,  and  counteracts  the  tendency  of  the  external  frag- 
ment to  be  carried  downward  by  the  weight  of  the  arm. 

The  strap  C.  D.  prevents  this  bandage  from  slipping  off  the 
shoulder. 


NOTE  VI. 
«  Fra<5hires  of  the  Femur."     Page  125. 

To  the  obje£lions  made  by  Boyer  to  Desault's  splint,  we  may 
^dd  the  difficulty  of  preventing  the  foot  from  turning  outward, 
and  carrying  with  it  the  inferior  fragment. 

A  bandage  passed  round  the  foot,  and  tied  to  the  internal  and 
external  splints,  offers  very  little  resistance.  The  internal  splint 
being  connedled  only  by  bandages  to  the  rest  of  the  apparatus 
is  drawn  outward  by  the  weight  of  the  foot. 

Another  very  great  inconvenience  in  the  use  of  Desault's 
splint  is,  that  the  bandages  by  which  extension  and  counter  ex- 
tension are  made,  aft  obliquely.  This  objeftion  has  been  in 
some  measure  obviated  by  improvements  made  in  the  construc- 
tion of  this  splint  by  Dr.  Physick,  and  Dr.  Hutchinson.  In 
iPlate  3.  we  have  endeavoured  to  give  a  view  of  these  improve- 
ments. 

a.  a.  a.    Represents  the  axis  of  the  os  femoris. 

D.  The  splint  first  used  by  Desault. 

d.  d.  d.  The  bandage  which  makes  the  counter  extension 

against  the  tuberosity  of  the  ischium. 

e.  e.  e.    The  bandage  passed  round  the  ancle,  for  the  purpose. 

of  making  extension. 

The  dotted  lines  P.  shew  the  addition  made  to  the  upper  ex- 
tremity of  this  splint  by  Dr.  Physick — p.  p.  p.  the  bandage 
which  makes  the  counter  extension. 

H.  The  block  added  by  Dr.  Hutchinson  to  the  lower  end  of 
the  sphnt,  and  h.  h.  h.  the  extending  bandage  passed  round  the 
ancle,  and  over  the  middle  of  the  block. 

The  upper  end  of  this  splint  is  excavated,  so  as  to  resemble 
the  head  of  a  crutch,  and  covered  with  a  cushion.  The  coun- 
ter extension  is  made  against  the  axilla  and  the  tuberosity  of 


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I. 

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NOTES.  365 

the  ischium.  It  is  sometimes  necessary  to  remove  the  bandage, 
in  order  to  examine  the  perineum.  Whenever  this  is  done, 
the  extension  may  still  be  continued,  by  making  the  whole  of 
the  counter  extension  against  the  axilla. 

The  obliquity  in  the  a£tion  of  the  extending  and  counter- 
extending  bandages,  is  thus  considerably  diminished;  but  it  is  by 
no  means  entirely  removed,  nor  is  any  provision  made  against 
the  tendency  of  the  foot  to  fall  outward. 

Should  the  alterations  which  I  am  about  to  propose  in  the 
construftion  of  Desault's  splint  be  deemed  worthy  of  a  fair  trial, 
future  experience  will  determine  whether  they  merit  the  name 
of  improvements.  Instead  of  the  bandage  which  Desault  di- 
re£ls  to  be  passed  between  the  scrotum  of  the  affected  limb,  and 
tied  to  the  external  splint,  for  the  purpose  of  making  the 
counter  extension,  a  piece  of  wood  of  an  elliptical  form,  is 
made  to  surround  the  anterior  and  lateral  parts  of  the  thigh. 
This  part  of  the  apparatus,  which  for  the  sake  of  brevity  shall 
be  called  the  semi-circle,  is  to  be  placed  on  the  thigh  as  in  fig.  1. 
Plate  if.  The  external  extremity  presses  against  the  spine  of  the 
ilium,  while  the  internal  compresses  the  tuberosity  of  the  is- 
chium. 

R.  R.  shew  two  lateral  proje£lions  pierced  with  holes.  They 
should  be  about  six  inches  in  length,  and  parallel  with  the  axis, 
of  the  OS  femoris. 

E.  F.  a  handkerchief  passed  through  a  hole  in  each  projec- 
tion, carried  under  the  thigh,  and  tied  at  F.  By  tightening  or 
relaxing  this  band,  the  circle  may  be  in  some  measure  enlarged 
or  diminished. 

Fig.  2,  is  a  view  of  the  apparatus  applied  to  the  left  thigh. 

A.  B.  the  splints  of  the  usual  length,  and  about  seven  in- 
ches in  width. 

C.     the  semi-circle. 

c.  c,  c.  c.  four  holes  in  the  external  splint,  with  the  tapes 
which  tie  it  to  the  external  lateral  projedlion.  The  internal 
splint  is  connected  in  the  same  manner,  to  the  internal  lateral 
projection. 

p.  the  cross  piece  upon  which  the  extension  is  made  by  a 
bandage  passed  round  the  ancle. 

a.  a.  a.  b.  b.  b.  bags  of  chaff,  scmev.'hat  wider  than  the 
splints. 

E.  F.  two  cross  pieces  passed  through  mortises  and  secured  by 
pegs.  They  serve  to  keep  steady  the  whole  apparatus,  and  by 
pressing  the  bags  of  chaff  against  the  Hmb,  they  prevent  the  foot 
from  turning  inward  or  outward. 


J 


66  NOTtS. 


G.    a  bandage  passed  round  the  pelvis  and  external  splint^ 
The    effects  of  pressure  should  be  guarded  against  by  ap- 
plying strips  of  adhesive  plaister  to  the  perineum,  over  the  spine 
of  the  ilium,  and  round  the  ancle.     A  bolster  should  also  be 
made  to  fit  the  upper  edge  of  the  semicircle. 

Tlie  bandage  which  passes  round  the  ancle  and  is  tied  to 
the  last  cross  piece,  draws  downward  the  inferior  fragment,  and 
at  the  same  time,  prevents  the  pelvis  and  superior  fragment 
from  descending,  by  pushing  upwards  the  internal  and  external 
splints.  By  the  former,  the  semi-circle  is  pressed  against  the 
tuberosity  of  the  ischium,  and  by  the  latter  against  the  spine  of 
the  ilium.  In  this  manner,  the  extension,  and  counter  exten- 
sion, are  made  ia  a  direction  parallel  with  the  axis  of  the  os 
femoris. 


NOTE  VII. 

"  "When  the  leg  is  fradlured  very  obliquely,  continued  ex- 
tension ought  to  be  employed."     Page  146. 

The  splints  invented  by  Dr.  Hutchinson  are  well  calculated 
to  fulfil  this  indication.  They  are  so  simple  in  their  construc- 
tion, that  a  satisfactory  description  oi:  them  may  be  given  with- 
out the  aid  of  a  plate. 

The  splints  are  about  four  inches  wide,  and  long  enough  to 
reach  from  the  knee  to  some  distance  beyond  the  foot.  The 
upper  end  of  each  has  four  holes.  At  the  lower  end  they  are 
connected  by  a  cross  piece  passed  through  mortises. 

This  apparatus  is  very  easily  applied.  For  the  purpose  of 
making  the  counter  extension,  two  pieces  of  tape  are  bound  to 
the  inside,  and  two  more  to  the  outside  of  the  leg,  by  a  band- 
age passed  round  the  limb,  just  below  the  knee.  With  these 
tapes,  the  upper  ends  of  the  splints  are  tied  to  the  bandage. 
Another  bandage  passed  round  the  ancle,  and  tied  to  the  cross 
piece,  makes  th^  extension. 


NOTE  VIII. 

"  The  extending  force  is  to  be  applied  to  the  inferior  part  of 
the  leg,  in  order  to  have  it  as  far  as  possible  from  the  part? 


NOTES.  367 

which  resist  the  return  of  the  head  of , the  femur.     Luxations 
of  the  femur."     Page  267. 

•  When  we  apply  the  extending  force  to  the  inferior  part  of 
the  hmb,  as  directed  by  Boyer,  we  must  extend  the  leg.  When 
this  is  done,  the  flexor  muscles  which  originate  from  the  pel- 
vis, and  are  inserted  into  the  leg,  have  the  same  effect  as  if  they 
were  inserted  into  the  os  femoris — viz.  they  draw  the  head  of 
the  bone  upwards,  and  offer  a  considerable  resistance  to  the 
reduction.  This  resistance  may  be  very  much  diminished  by 
bending  the  leg. 

Two  cases  of  luxated  os  femoris,  came  under  the  care  of 
Dr.  Physick  last  winter,  in  the  Pennsylvania  Hospital.  In  the 
first  attempts  which  were  made  to  reduce  these  dislocations, 
the  extending  bandage  was  placed  above  the  knee. 

Whenever  any  considerable  degree  of  extension  was  made, 
the  bandage  slipped.  It  was  necessary  then,  either  to  pass  the 
bandage  round  the  ancle,  and  extend  the  leg;  or  to  flex  the 
leg,  and  apply  the  bandage  just  below  the  knee.  Dr.  Physick 
preferred  the  latter,  and  soon  after  accomplished  the  redudlion. 


POSTCRIPT. 


On  the  second  of  August,  several  days  after  the  foregoing 
notes  had  been  handed  to  the  printer,  the  editor  was  called  to 
a  case  of  oblique  fradlure  of  the  os  femoris.  The  patient  was 
a  child  aged  two  years  and  five  months.  Desault's  splint  was 
applied  and  had  a  very  happy  effecl  in  lessening  pain,  by  re- 
straining the  convulsive  adtion  of  the  muscles.  On  the  next 
day  however,  the  patient  became  extremely  restless.  The 
counterextending  bandage  had  so  much  excoriated  the  perine- 
um, that  every  attempt  to  increase  the  extension  gave  great 
pain. 

In  the  afternoon,  thirty-three  hours  after  the  accident,  this 
dressing  was  removed,  and  the  apparatus  delineated  in  Plate  4 
was  applied. 

Dr.  James  Hutchinson  very  obligingly  offered  to  witness  the 
effefts  of  this  method  of  dressing  fractures  of  the  thigh. 

It  was  the  opinion  of  this  gentleman,  that  the  necessary  de- 
gree of  extension  in  this  case  was  made  with  little  force,  an<i 
consequently  with  little  pain,  in  a  dire£lion  parallel  with  the 


368  NOTES. 

> 
axis  of  the  os  femoris :  that  the  foot  with  the  inferior  fragment 

were  efFedhially  prevented  from  turning  either  inward  or  out- 
ward. 

The  child  is  now  (8th  August)  entirely  free  fi"om  pain,  and 
no  difference  can  be  perceived  in  the  length  of  the  lower  ex- 
tremities. 


THE    END. 


PRACTICAL  OBSERVATIONS  IN  SURGERY, 

ILtUSTRATED    WITH 

CASES  AND  PLATES: 
Br  WILLIAM  HEY,  Esq,  F.  R.  S. 

Member  of  the  Roya^  College  of  Surgeons  in  London:    Honorary  Member  of  the  Royal 

Medical  Society  of  Edinburgh ;  and  of  the  "Literary  and  Philosophical  Society 

of  Manchester  :    And  Senior  Surgeon  of  the  General  Infirmary  at  Leeds. 

THE    FOREGOING    WORK 

Is  in  the  Press  of  James  Humphreys,  printing  on  Subscription, 

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:";>>: 


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■':■:■     ' 


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Date  Due 

L.  B.  Cat.  No.  1 137 

1 

Richerand 


4;i4wb 


Diseaaea   of  the  Bones 


316.71       R359 


43498 


